Provider Demographics
NPI:1487325460
Name:STALLWORTH, ANDREA Y (NCC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:Y
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 AZALEA DR APT 1424
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-2194
Mailing Address - Country:US
Mailing Address - Phone:630-624-6561
Mailing Address - Fax:
Practice Address - Street 1:106 S LINCOLNWAY STE E
Practice Address - Street 2:
Practice Address - City:NORTH AURORA
Practice Address - State:IL
Practice Address - Zip Code:60542-1597
Practice Address - Country:US
Practice Address - Phone:630-624-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health