Provider Demographics
NPI:1265946040
Name:ANDERSON, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ANDERSON
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 1:26777 LORAIN RD STE 412
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26777 LORAIN RD STE 412
Practice Address - Street 2:
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-3224
Practice Address - Country:US
Practice Address - Phone:330-221-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2002687101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1265946040Medicaid