Provider Demographics
NPI:1205384435
Name:ADA, ANDREA (ACSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ADA
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 FATHER DUENAS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96910-5058
Mailing Address - Country:US
Mailing Address - Phone:671-788-0663
Mailing Address - Fax:
Practice Address - Street 1:790 GOVERNOR CARLOS CAMACHO ROAD
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-647-2057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA64838104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker