Provider Demographics
NPI:1598224958
Name:CARBUNGCO, ANDREW S
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:S
Last Name:CARBUNGCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16205 NW BETHANY CT STE 116
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4687
Mailing Address - Country:US
Mailing Address - Phone:503-860-6525
Mailing Address - Fax:503-747-4210
Practice Address - Street 1:16205 NW BETHANY CT STE 116
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4687
Practice Address - Country:US
Practice Address - Phone:503-860-6525
Practice Address - Fax:503-747-4210
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10174239106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician