Provider Demographics
NPI:1588672935
Name:NOVAK, ANDREAS (MSW, LISW)
Entity Type:Individual
Prefix:MR
First Name:ANDREAS
Middle Name:
Last Name:NOVAK
Suffix:
Gender:M
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6710 HIGH POINT DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-0954
Mailing Address - Country:US
Mailing Address - Phone:505-327-0505
Mailing Address - Fax:
Practice Address - Street 1:3300 N BUTLER AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5621
Practice Address - Country:US
Practice Address - Phone:505-327-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-23641041C0700X
CO9830431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00JK65OtherBLUE CROSS/BLUE SHIELD #