Provider Demographics
NPI:1841504859
Name:PHILLIPS, ANDREA C (REG INTERN # 63262)
Entity type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:C
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:REG INTERN # 63262
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262
Mailing Address - Country:US
Mailing Address - Phone:310-691-0793
Mailing Address - Fax:310-631-5918
Practice Address - Street 1:3737 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3513
Practice Address - Country:US
Practice Address - Phone:310-691-0793
Practice Address - Fax:310-631-5918
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63262106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist