Provider Demographics
NPI:1760953913
Name:DE ANDA, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:DE ANDA
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 1:10513 MAGNOLIA AVE SPC G4
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1830
Mailing Address - Country:US
Mailing Address - Phone:562-822-3809
Mailing Address - Fax:
Practice Address - Street 1:10513 MAGNOLIA AVE SPC G4
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1830
Practice Address - Country:US
Practice Address - Phone:562-822-3809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician