1114222064 NPI number — ANDREA MICHELE EMMONS LCSW

Table of content: ANDREA MICHELE EMMONS LCSW (NPI 1114222064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114222064 NPI number — ANDREA MICHELE EMMONS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EMMONS
Provider First Name:
ANDREA
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114222064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
847 PARK CENTRE WAY STE. 4
Provider Second Line Business Mailing Address:
CORE COUNSELING CENTER
Provider Business Mailing Address City Name:
NAMPA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-467-2673
Provider Business Mailing Address Fax Number:
208-467-4150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
847 PARK CENTRE WAY STE. 4
Provider Second Line Business Practice Location Address:
CORE COUNSELING CENTER
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-2673
Provider Business Practice Location Address Fax Number:
208-467-4150
Provider Enumeration Date:
01/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW30993 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1255412714 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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