Provider Demographics
NPI:1710329990
Name:INTAGLIATA, ANDREW JOHN
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:JOHN
Last Name:INTAGLIATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6461 WHITEFORD CENTER RD
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48144-9474
Mailing Address - Country:US
Mailing Address - Phone:419-461-0990
Mailing Address - Fax:
Practice Address - Street 1:701 JEFFERSON AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-6955
Practice Address - Country:US
Practice Address - Phone:419-244-5511
Practice Address - Fax:419-321-6459
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1200115101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health