Provider Demographics
NPI:1124318134
Name:BOHMBACH, ANDREA (IMF)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BOHMBACH
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 KELLER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:CA
Mailing Address - Zip Code:94517-1915
Mailing Address - Country:US
Mailing Address - Phone:858-243-8444
Mailing Address - Fax:
Practice Address - Street 1:2245 BACON ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2021
Practice Address - Country:US
Practice Address - Phone:925-827-3857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70948106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program