Provider Demographics
NPI:1750311379
Name:DAVIS, ANDREA MARIE (LPC-S, ATR-BC)
Entity Type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC-S, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 GROVELAND DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-4217
Mailing Address - Country:US
Mailing Address - Phone:214-673-3571
Mailing Address - Fax:214-237-1269
Practice Address - Street 1:2007 N COLLINS BLVD STE 411
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2665
Practice Address - Country:US
Practice Address - Phone:972-544-6633
Practice Address - Fax:214-237-1269
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20227101YM0800X, 101YP2500X
TX221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182346001Medicaid
TX728210OtherVALUE OPTIONS/ NORTHSTAR