Provider Demographics
NPI:1568470243
Name:ANDRES, MARIDEL (PHD)
Entity Type:Individual
Prefix:
First Name:MARIDEL
Middle Name:
Last Name:ANDRES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 234
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-0234
Mailing Address - Country:US
Mailing Address - Phone:970-254-1686
Mailing Address - Fax:
Practice Address - Street 1:2754 COMPASS DR
Practice Address - Street 2:STE 170
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8714
Practice Address - Country:US
Practice Address - Phone:970-254-1686
Practice Address - Fax:970-254-1687
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2293103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07022932Medicaid
CO07022932Medicaid
S56742Medicare UPIN