Provider Demographics
NPI:1891439410
Name:DAVIS, ANDREA LI'STAR
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:LI'STAR
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 S 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-2945
Mailing Address - Country:US
Mailing Address - Phone:708-712-1663
Mailing Address - Fax:
Practice Address - Street 1:1837 S 20TH AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-2945
Practice Address - Country:US
Practice Address - Phone:708-712-1663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker