Provider Demographics
NPI:1427305754
Name:CLOW, ANDREA T (LAC, LMT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:T
Last Name:CLOW
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W 7TH ST
Mailing Address - Street 2:APT 22
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-0300
Mailing Address - Country:US
Mailing Address - Phone:704-796-5220
Mailing Address - Fax:
Practice Address - Street 1:14650 AVIATION BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-6668
Practice Address - Country:US
Practice Address - Phone:310-725-8505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 14910171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist