Provider Demographics
NPI:1528253705
Name:MANGRAM SIMMONS, ANDREA C
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:C
Last Name:MANGRAM SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ANDREA
Other - Middle Name:C
Other - Last Name:MANGRAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1850 CAMERON GLEN DRIVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190
Mailing Address - Country:US
Mailing Address - Phone:703-481-4154
Mailing Address - Fax:703-435-1961
Practice Address - Street 1:1850 CAMERON GLEN DRIVE
Practice Address - Street 2:SUITE 600
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-481-4154
Practice Address - Fax:703-435-1961
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904002161104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker