Provider Demographics
NPI:1942722301
Name:WANZA, ANDREA (LMHC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WANZA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 IVES DAIRY RD STE 228
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-2538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 NW 183RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-4468
Practice Address - Country:US
Practice Address - Phone:305-654-7251
Practice Address - Fax:305-647-0203
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14491101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH14491OtherSTATE LICENSE