Provider Demographics
NPI:1912149196
Name:PHILLIPS, ANDREA LYNN (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LYNN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:LYNN
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:28518 COUNTY ROUTE 192
Mailing Address - Street 2:
Mailing Address - City:REDWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:13679-4136
Mailing Address - Country:US
Mailing Address - Phone:315-486-5203
Mailing Address - Fax:
Practice Address - Street 1:1635 OHIO ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3032
Practice Address - Country:US
Practice Address - Phone:315-786-7285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012436-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist