Provider Demographics
NPI:1003520057
Name:BOULWARE, ANDREA (LCMHCA)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 SUMMIT VIEW PL
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7333
Mailing Address - Country:US
Mailing Address - Phone:980-243-3646
Mailing Address - Fax:
Practice Address - Street 1:7300 CARMEL EXECUTIVE PARK DR STE 115
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-1310
Practice Address - Country:US
Practice Address - Phone:980-243-3646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health