Provider Demographics
NPI:1912132937
Name:LAST, ANDREW (LMFT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:LAST
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6393 BADGER LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3316
Mailing Address - Country:US
Mailing Address - Phone:619-272-1522
Mailing Address - Fax:
Practice Address - Street 1:2635 CAMINO DEL RIO S STE 211
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3729
Practice Address - Country:US
Practice Address - Phone:619-786-1356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA80886106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner