Provider Demographics
NPI:1417617929
Name:ANDRADE, BREANNY
Entity Type:Individual
Prefix:
First Name:BREANNY
Middle Name:
Last Name:ANDRADE
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 1:16360 ROSCOE BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-1219
Mailing Address - Country:US
Mailing Address - Phone:818-826-1345
Mailing Address - Fax:
Practice Address - Street 1:16360 ROSCOE BLVD FL 2
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-1219
Practice Address - Country:US
Practice Address - Phone:818-826-1345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-23
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
CA1124451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner