Provider Demographics
NPI:1760860779
Name:DE ANDA, RAY
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:DE ANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 MCHENRY VILLAGE WAY STE 11
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4341
Mailing Address - Country:US
Mailing Address - Phone:209-526-1476
Mailing Address - Fax:209-526-0908
Practice Address - Street 1:1700 MCHENRY VILLAGE WAY STE 11
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4341
Practice Address - Country:US
Practice Address - Phone:209-526-1476
Practice Address - Fax:209-526-0908
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)