Provider Demographics
NPI:1306601158
Name:ANDREA E KIRK PHD
Entity type:Organization
Organization Name:ANDREA E KIRK PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:707-393-5475
Mailing Address - Street 1:309 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4208
Mailing Address - Country:US
Mailing Address - Phone:707-939-5475
Mailing Address - Fax:
Practice Address - Street 1:309 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4208
Practice Address - Country:US
Practice Address - Phone:707-939-5475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty