Provider Demographics
NPI:1881041002
Name:HUDDLESTON, ANDRE MICHAEL SR
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:MICHAEL
Last Name:HUDDLESTON
Suffix:SR
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 1:11879 FIRE AGATE WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95742-8068
Mailing Address - Country:US
Mailing Address - Phone:916-549-0821
Mailing Address - Fax:
Practice Address - Street 1:11879 FIRE AGATE WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-8068
Practice Address - Country:US
Practice Address - Phone:916-549-0821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA171M00000X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator