Provider Demographics
NPI:1912114745
Name:FOUTZ, ANDREA LUCAS (EDS)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LUCAS
Last Name:FOUTZ
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6065 CHAGALL DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5289
Mailing Address - Country:US
Mailing Address - Phone:540-725-8429
Mailing Address - Fax:540-989-6360
Practice Address - Street 1:2910 FLEETWOOD AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-4626
Practice Address - Country:US
Practice Address - Phone:540-989-6360
Practice Address - Fax:540-989-6360
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool