Provider Demographics
NPI:1114222064
Name:EMMONS, ANDREA MICHELE (LCSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MICHELE
Last Name:EMMONS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 PARK CENTRE WAY STE. 4
Mailing Address - Street 2:CORE COUNSELING CENTER
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83646
Mailing Address - Country:US
Mailing Address - Phone:208-467-2673
Mailing Address - Fax:208-467-4150
Practice Address - Street 1:847 PARK CENTRE WAY STE. 4
Practice Address - Street 2:CORE COUNSELING CENTER
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83646
Practice Address - Country:US
Practice Address - Phone:208-467-2673
Practice Address - Fax:208-467-4150
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW309931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1255412714Medicaid