Provider Demographics
NPI:1801211891
Name:TRUJILLO, ANDREA I
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:TRUJILLO
Suffix:I
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 1:3020 E BONANZA RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-3702
Mailing Address - Country:US
Mailing Address - Phone:702-771-9128
Mailing Address - Fax:702-982-3069
Practice Address - Street 1:3020 E BONANZA SUITE 160-A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101
Practice Address - Country:US
Practice Address - Phone:702-771-9128
Practice Address - Fax:702-982-3069
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20131063992103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV46-1989499Medicaid