Provider Demographics
NPI:1346628328
Name:ROYAL, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:ROYAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 W GLEN OAKS LN
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3467
Mailing Address - Country:US
Mailing Address - Phone:262-241-7778
Mailing Address - Fax:
Practice Address - Street 1:1045 W GLEN OAKS LN
Practice Address - Street 2:SUITE 1
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3467
Practice Address - Country:US
Practice Address - Phone:262-241-7778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6362-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional