Provider Demographics
NPI:1528349370
Name:MIKONOWICZ, ANDREA ELLEN (MA LMFT)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:ELLEN
Last Name:MIKONOWICZ
Suffix:
Gender:F
Credentials:MA LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4237 INGLEWOOD BLVD
Mailing Address - Street 2:APT 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5870
Mailing Address - Country:US
Mailing Address - Phone:310-902-6854
Mailing Address - Fax:
Practice Address - Street 1:4237 INGLEWOOD BLVD
Practice Address - Street 2:APT 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5870
Practice Address - Country:US
Practice Address - Phone:310-902-6854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2014-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 52248106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist