Provider Demographics
NPI:1679610505
Name:PRAIRIE TULLEY, ANDREA (LPC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PRAIRIE TULLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 DARTMOUTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 ALBANY TURNPIKE
Practice Address - Street 2:SUITE #5022
Practice Address - City:CANTON
Practice Address - State:CT
Practice Address - Zip Code:06019
Practice Address - Country:US
Practice Address - Phone:860-490-8084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001460101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional