Provider Demographics
NPI:1548092505
Name:PHONPHIBOUN, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PHONPHIBOUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9720 RANCHO HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-8312
Mailing Address - Country:US
Mailing Address - Phone:510-945-9239
Mailing Address - Fax:
Practice Address - Street 1:9720 RANCHO HILLS DR
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-8312
Practice Address - Country:US
Practice Address - Phone:510-945-9239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician