Provider Demographics
NPI:1518123827
Name:MACKEN, ANDREA MICHELE (B,C,B,A,)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MICHELE
Last Name:MACKEN
Suffix:
Gender:F
Credentials:B,C,B,A,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40485 MURRIETA HOT SPRINGS RD
Mailing Address - Street 2:SUITE B-4, #146
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-6406
Mailing Address - Country:US
Mailing Address - Phone:619-804-3401
Mailing Address - Fax:
Practice Address - Street 1:41951 REMINGTON AVE
Practice Address - Street 2:STE 210
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2552
Practice Address - Country:US
Practice Address - Phone:951-813-4034
Practice Address - Fax:951-813-4035
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1052486103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst