Provider Demographics
NPI:1841892833
Name:GAMMAGE, ANDREA LYNNE (PRS CATC IV)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNNE
Last Name:GAMMAGE
Suffix:
Gender:F
Credentials:PRS CATC IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25057 W POSEY DR
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-2741
Mailing Address - Country:US
Mailing Address - Phone:909-938-2381
Mailing Address - Fax:
Practice Address - Street 1:85 RAMONA EXPY STE 1
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-7014
Practice Address - Country:US
Practice Address - Phone:951-349-4195
Practice Address - Fax:951-490-0123
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA167972IV101YA0400X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)