Provider Demographics
NPI:1851068977
Name:FORMENTINI, ANDREW (MS, ED)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:FORMENTINI
Suffix:
Gender:M
Credentials:MS, ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 E IRON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-2312
Mailing Address - Country:US
Mailing Address - Phone:847-372-4343
Mailing Address - Fax:
Practice Address - Street 1:1738 E IRON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-2312
Practice Address - Country:US
Practice Address - Phone:847-372-4343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3001023459101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool