Provider Demographics
NPI:1841823747
Name:PENA OFFERDAHL, ANDREA NICOLE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:PENA OFFERDAHL
Suffix:
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 1:1870 CORDELL CT
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-0914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1870 CORDELL CT
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-0914
Practice Address - Country:US
Practice Address - Phone:619-448-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW90741104100000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker