Provider Demographics
NPI:1508154725
Name:DILLINGHAM, ANDREW R (LMLP)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:R
Last Name:DILLINGHAM
Suffix:
Gender:M
Credentials:LMLP
Other - Prefix:
Other - First Name:ANDY
Other - Middle Name:
Other - Last Name:DILLINGHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 807
Mailing Address - Street 2:304 N. JEFFERSON AVE
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-2327
Mailing Address - Country:US
Mailing Address - Phone:620-365-8641
Mailing Address - Fax:620-365-8642
Practice Address - Street 1:505 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:KS
Practice Address - Zip Code:66075-4095
Practice Address - Country:US
Practice Address - Phone:913-352-8214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LMLP 1394103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200732040AMedicaid