Provider Demographics
NPI:1154621027
Name:MILLEVILLE, ANDREA RENE (LMSW)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:RENE
Last Name:MILLEVILLE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 VICTORIA BLVD
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2315
Mailing Address - Country:US
Mailing Address - Phone:716-297-0798
Mailing Address - Fax:716-297-0998
Practice Address - Street 1:115 VICTORIA BLVD
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2315
Practice Address - Country:US
Practice Address - Phone:716-297-0798
Practice Address - Fax:716-297-0998
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080843-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY080843-1OtherNYS LICENSE