Provider Demographics
NPI:1104039536
Name:MICK, ANDREA LYNN (MS CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:LYNN
Last Name:MICK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1850 BASSETT ST
Mailing Address - Street 2:921
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-1048
Mailing Address - Country:US
Mailing Address - Phone:843-367-3636
Mailing Address - Fax:
Practice Address - Street 1:3505 LAKE LYNDA DR
Practice Address - Street 2:SUITE 207
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8324
Practice Address - Country:US
Practice Address - Phone:877-896-3660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3776235Z00000X
TX102961235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist