Provider Demographics
NPI:1811192354
Name:COULTER, ANDRA ALISE (MFT)
Entity Type:Individual
Prefix:
First Name:ANDRA
Middle Name:ALISE
Last Name:COULTER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4629 MONONGAHELA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-2416
Mailing Address - Country:US
Mailing Address - Phone:619-977-7485
Mailing Address - Fax:
Practice Address - Street 1:2031 2ND AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2015
Practice Address - Country:US
Practice Address - Phone:619-977-7485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 41989106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist