Provider Demographics
NPI:1811514045
Name:DALE, ANDREW ALAN
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:ALAN
Last Name:DALE
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 1:135 CIELO LN APT 303
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-3310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 CIELO LN APT 303
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-3310
Practice Address - Country:US
Practice Address - Phone:805-868-9086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14049-RAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD6710328Medicaid