Provider Demographics
NPI:1477782498
Name:BUBBERT, ANDREA MARIE
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MARIE
Last Name:BUBBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:MORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 DUARTE RD
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-3012
Mailing Address - Country:US
Mailing Address - Phone:626-218-1202
Mailing Address - Fax:626-930-5331
Practice Address - Street 1:1500 DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-3012
Practice Address - Country:US
Practice Address - Phone:626-218-1202
Practice Address - Fax:626-930-5331
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-12
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CALCSW681681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner