Provider Demographics
NPI:1386081784
Name:PHILLIPS, ANDREA M
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:M
Other - Last Name:NORVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICENSE
Mailing Address - Street 1:315 NEWPORT RD
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-1627
Mailing Address - Country:US
Mailing Address - Phone:516-761-8162
Mailing Address - Fax:
Practice Address - Street 1:100 N PARK AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4157
Practice Address - Country:US
Practice Address - Phone:516-678-0707
Practice Address - Fax:516-678-5990
Is Sole Proprietor?:No
Enumeration Date:2013-05-27
Last Update Date:2013-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY868548174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XOtherTEACHER