Provider Demographics
NPI:1790918050
Name:ANDALON, JOSE T
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:T
Last Name:ANDALON
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 1:3525 HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-2966
Mailing Address - Country:US
Mailing Address - Phone:209-719-8105
Mailing Address - Fax:209-269-3225
Practice Address - Street 1:3525 HAWAII AVE
Practice Address - Street 2:
Practice Address - City:RIVERBANK
Practice Address - State:CA
Practice Address - Zip Code:95367-2966
Practice Address - Country:US
Practice Address - Phone:209-719-8105
Practice Address - Fax:209-269-3225
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
CALMFT127362106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator