Provider Demographics
NPI:1396364071
Name:GANDY-EDMUNDSON, DOREATHA YVONNE (LCSW)
Entity Type:Individual
Prefix:
First Name:DOREATHA
Middle Name:YVONNE
Last Name:GANDY-EDMUNDSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 NORTH CENTRE CITY PARKWAY
Mailing Address - Street 2:UNIT 103
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069
Mailing Address - Country:US
Mailing Address - Phone:858-472-5497
Mailing Address - Fax:
Practice Address - Street 1:112 NORTH CENTRE CITY PARKWAY
Practice Address - Street 2:UNIT 103
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069
Practice Address - Country:US
Practice Address - Phone:858-472-5497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA919931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty