Provider Demographics
NPI:1053515817
Name:DE ANDA, FERNANDO
Entity type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:
Last Name:DE ANDA
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 1:12 W BEACH ST STE 219
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-4504
Mailing Address - Country:US
Mailing Address - Phone:831-763-8990
Mailing Address - Fax:
Practice Address - Street 1:1430 FREEDOM BLVD STE F
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-2752
Practice Address - Country:US
Practice Address - Phone:831-763-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA6489688OtherD.L