Basic Information
| Provider Information | |||||||||
| NPI: | 1003005190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGORIA | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | ROAD-TRAVELER | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 518 LOW GAP RD | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954823735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074634968 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 518 LOW GAP RD | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954823735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074634968 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2007 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.