Provider Demographics
NPI:1710297742
Name:MILLSAP, ANDREA E
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:E
Last Name:MILLSAP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9599 W CHARLESTON BLVD STE 1169
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-6654
Mailing Address - Country:US
Mailing Address - Phone:702-715-7887
Mailing Address - Fax:
Practice Address - Street 1:9599 W CHARLESTON BLVD APT 1169
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-6670
Practice Address - Country:US
Practice Address - Phone:702-715-7887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005056211Medicaid