Provider Demographics
NPI:1568520559
Name:ANDRZEJCZAK, ANDREA LYNN (PHD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNN
Last Name:ANDRZEJCZAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20867 MACK AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1392
Mailing Address - Country:US
Mailing Address - Phone:313-885-8350
Mailing Address - Fax:313-885-8357
Practice Address - Street 1:17850 MAUMEE AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1612
Practice Address - Country:US
Practice Address - Phone:313-885-8350
Practice Address - Fax:313-885-8357
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009783103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N25460Medicare ID - Type Unspecified