Provider Demographics
NPI:1760590392
Name:ANDRADE, SCOTT GOMES (MA)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:GOMES
Last Name:ANDRADE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2291 WEST MARCH LANE
Mailing Address - Street 2:SUITE D-200
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6670
Mailing Address - Country:US
Mailing Address - Phone:209-969-5547
Mailing Address - Fax:209-825-5996
Practice Address - Street 1:2291 WEST MARCH LANE
Practice Address - Street 2:SUITE D-200
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6670
Practice Address - Country:US
Practice Address - Phone:209-969-5547
Practice Address - Fax:209-825-5996
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38968106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist