Provider Demographics
NPI:1609179399
Name:ANDALORO, KELLY (CDCII)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ANDALORO
Suffix:
Gender:F
Credentials:CDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3504 INDUSTRIAL AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7376
Mailing Address - Country:US
Mailing Address - Phone:907-388-3221
Mailing Address - Fax:907-459-8201
Practice Address - Street 1:3504 INDUSTRIAL AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7376
Practice Address - Country:US
Practice Address - Phone:907-388-3221
Practice Address - Fax:907-459-8201
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2139101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK2139OtherALASKA COMMISSION FOR BEHAVIORAL HEALTH CERTIFICATION