Provider Demographics
NPI:1336743517
Name:KING, ANDREA J (MA, LPC, NCC)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:J
Last Name:KING
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 S MICHIGAN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3484
Mailing Address - Country:US
Mailing Address - Phone:773-816-5504
Mailing Address - Fax:
Practice Address - Street 1:2930 S MICHIGAN AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3484
Practice Address - Country:US
Practice Address - Phone:773-819-5504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-28
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
178.015844101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL84191597001Medicaid