Provider Demographics
NPI:1619391539
Name:MOSQUERA, AUDREY K
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:K
Last Name:MOSQUERA
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 1:300 SUNNYHILLS DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1909
Mailing Address - Country:US
Mailing Address - Phone:415-457-3200
Mailing Address - Fax:
Practice Address - Street 1:300 SUNNYHILLS DR
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-1909
Practice Address - Country:US
Practice Address - Phone:415-457-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66661101YM0800X, 104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health