Provider Demographics
NPI:1245752575
Name:LASCANO, ANDROMEDA
Entity Type:Individual
Prefix:
First Name:ANDROMEDA
Middle Name:
Last Name:LASCANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 COFFEE RD STE A2
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1582
Mailing Address - Country:US
Mailing Address - Phone:209-524-9401
Mailing Address - Fax:209-491-7584
Practice Address - Street 1:3425 COFFEE RD STE A2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1582
Practice Address - Country:US
Practice Address - Phone:209-524-9401
Practice Address - Fax:209-491-7584
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CALMFT133104106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional