Provider Demographics
NPI:1083623391
Name:MASOM, ANDREA L (LCPC)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:L
Last Name:MASOM
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E 3RD ST
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2970
Mailing Address - Country:US
Mailing Address - Phone:208-882-1289
Mailing Address - Fax:208-882-8406
Practice Address - Street 1:106 E 3RD ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2970
Practice Address - Country:US
Practice Address - Phone:208-882-1289
Practice Address - Fax:208-882-8406
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC#3017101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ5977OtherBLUE CROSS