Provider Demographics
NPI:1003577370
Name:DIPASTENA, ANDREW WILLIAM (MFT TEMP LICENSE)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:WILLIAM
Last Name:DIPASTENA
Suffix:
Gender:M
Credentials:MFT TEMP LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 EVERHART DR NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-1622
Mailing Address - Country:US
Mailing Address - Phone:423-544-0199
Mailing Address - Fax:
Practice Address - Street 1:2200 CHAMBLISS AVE NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3874
Practice Address - Country:US
Practice Address - Phone:423-599-9347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN1914106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program