Provider Demographics
NPI:1316190259
Name:FRESH, ANDREA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:
Last Name:FRESH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 S SCHILLER ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-5817
Mailing Address - Country:US
Mailing Address - Phone:501-507-0675
Mailing Address - Fax:501-421-0107
Practice Address - Street 1:1408 S SCHILLER ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-5817
Practice Address - Country:US
Practice Address - Phone:501-507-0675
Practice Address - Fax:501-421-0107
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2117-C101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180635526Medicaid