Provider Demographics
NPI:1750940722
Name:GOLLEGLY, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:GOLLEGLY
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 1:1219 DUNN AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2405
Mailing Address - Country:US
Mailing Address - Phone:386-944-7813
Mailing Address - Fax:386-252-3403
Practice Address - Street 1:1673 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5515
Practice Address - Country:US
Practice Address - Phone:386-944-7813
Practice Address - Fax:386-252-3403
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0000000000Medicaid