Provider Demographics
NPI:1811557473
Name:BAIN-FRYE, ANDREA LEIGH (LPC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEIGH
Last Name:BAIN-FRYE
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 1:2613 E SUNRISE CT
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:SD
Mailing Address - Zip Code:57005-6673
Mailing Address - Country:US
Mailing Address - Phone:419-870-6113
Mailing Address - Fax:
Practice Address - Street 1:1627 HENTHORNE DR STE C
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1370
Practice Address - Country:US
Practice Address - Phone:419-491-0420
Practice Address - Fax:567-698-7875
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1800919101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0373567Medicaid