Provider Demographics
NPI:1295531549
Name:SMITH, ANDREA SUZANNE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:SUZANNE
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:WI
Mailing Address - Zip Code:54614-8794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3936 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-9187
Practice Address - Country:US
Practice Address - Phone:608-413-4825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician