Provider Demographics
NPI:1710609565
Name:SEPULVEDA, ANDY (ATC)
Entity Type:Individual
Prefix:MS
First Name:ANDY
Middle Name:
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MS
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:SEPULVEDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1797 N WILLOW WOODS DR UNIT C
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-1459
Mailing Address - Country:US
Mailing Address - Phone:714-404-7916
Mailing Address - Fax:
Practice Address - Street 1:4515 PORTOLA PKWY
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-2200
Practice Address - Country:US
Practice Address - Phone:949-936-7244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020002011OtherBOC