Provider Demographics
NPI:1245330620
Name:MALTESE, ANDREA LYNN (LCSW)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:LYNN
Last Name:MALTESE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1136 W 17TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3002
Mailing Address - Country:US
Mailing Address - Phone:812-318-1695
Mailing Address - Fax:
Practice Address - Street 1:600 N JORDAN AVE
Practice Address - Street 2:CAPS #448
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3190
Practice Address - Country:US
Practice Address - Phone:812-855-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005719A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945018Medicaid