Provider Demographics
NPI:1255689022
Name:FAFFORD, ANDREA K-P (LCSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:K-P
Last Name:FAFFORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:K
Other - Last Name:PERATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3708 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-2441
Mailing Address - Country:US
Mailing Address - Phone:414-218-3413
Mailing Address - Fax:
Practice Address - Street 1:6501 3RD AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5111
Practice Address - Country:US
Practice Address - Phone:262-914-6540
Practice Address - Fax:262-997-1061
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7912-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100085186Medicaid