Provider Demographics
NPI:1831666239
Name:HEINLEIN, ANDREA NEAL (LICSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NEAL
Last Name:HEINLEIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 S TASSAJARA DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1559
Mailing Address - Country:US
Mailing Address - Phone:617-833-7110
Mailing Address - Fax:
Practice Address - Street 1:55 S TASSAJARA DR
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1559
Practice Address - Country:US
Practice Address - Phone:617-833-7110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1011881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA101188-SW-LICSWOtherSOCIAL WORK LICENSE