Provider Demographics
NPI:1881178952
Name:EZPELETA, ANDREW THEODORE (ACSW)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:THEODORE
Last Name:EZPELETA
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 676
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0676
Mailing Address - Country:US
Mailing Address - Phone:360-213-5907
Mailing Address - Fax:
Practice Address - Street 1:27261 LAS RAMBLAS STE 220
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6468
Practice Address - Country:US
Practice Address - Phone:714-966-8650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84637101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health