Provider Demographics
NPI:1457425647
Name:FARRA, ANDREW R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:R
Last Name:FARRA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 EMERSON ST STE 202
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3100
Mailing Address - Country:US
Mailing Address - Phone:847-859-9094
Mailing Address - Fax:
Practice Address - Street 1:1123 EMERSON ST STE 202
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3100
Practice Address - Country:US
Practice Address - Phone:847-859-9094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-007609103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH77006655Y0NH01OtherBHN
NH99003227Medicaid
NHNH3227Medicare ID - Type Unspecified