1255689022 NPI number — ANDREA K-P FAFFORD LCSW

Table of content: ANDREA K-P FAFFORD LCSW (NPI 1255689022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255689022 NPI number — ANDREA K-P FAFFORD LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAFFORD
Provider First Name:
ANDREA
Provider Middle Name:
K-P
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:
PERATT
Provider Other First Name:
ANDREA
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255689022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3708 16TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENOSHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53140-2441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-218-3413
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6501 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53143-5111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-914-6540
Provider Business Practice Location Address Fax Number:
262-997-1061
Provider Enumeration Date:
08/27/2012

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:  7912-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100085186 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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