Provider Demographics
NPI:1659431757
Name:GLETTY, ANDI M (CADCII A3773397)
Entity Type:Individual
Prefix:
First Name:ANDI
Middle Name:M
Last Name:GLETTY
Suffix:
Gender:F
Credentials:CADCII A3773397
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10899 NORTH SLOPE DRIVE
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451
Mailing Address - Country:US
Mailing Address - Phone:707-994-7090
Mailing Address - Fax:707-994-7096
Practice Address - Street 1:15145A LAKESHORE DRIVE
Practice Address - Street 2:LAKE COUNTY MENTAL HEALTH
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422
Practice Address - Country:US
Practice Address - Phone:707-994-7090
Practice Address - Fax:707-994-7096
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA3773397101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)