Provider Demographics
NPI:1124586813
Name:CONANAN, ANDREA KAMILLE (MS)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:KAMILLE
Last Name:CONANAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 FENTON PKWY STE 107-257
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4746
Mailing Address - Country:US
Mailing Address - Phone:858-707-5301
Mailing Address - Fax:
Practice Address - Street 1:3130 5TH AVE # 3
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5839
Practice Address - Country:US
Practice Address - Phone:858-707-5301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13059101YP2500X, 101YM0800X
CA5241101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional