Provider Demographics
NPI:1881699452
Name:DECANDIA, ROBERTO D (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:D
Last Name:DECANDIA
Suffix:
Gender:M
Credentials:PHD
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 5163
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-0163
Mailing Address - Country:US
Mailing Address - Phone:626-299-4700
Mailing Address - Fax:
Practice Address - Street 1:1000 S FREMONT AVE
Practice Address - Street 2:EASTERN LOS ANGELES REGIONAL CENTER
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91802-7916
Practice Address - Country:US
Practice Address - Phone:626-299-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12012103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY120120OtherMEDI-CAL
CAPSY120120OtherMEDI-CAL