Provider Demographics
NPI:1336527563
Name:ESTEPHAN, ANDRE
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:ESTEPHAN
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 1:950 W SIERRA MADRE AVE
Mailing Address - Street 2:APT 614
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-1800
Mailing Address - Country:US
Mailing Address - Phone:626-327-5711
Mailing Address - Fax:
Practice Address - Street 1:3827 E COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3935
Practice Address - Country:US
Practice Address - Phone:626-327-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85912106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist