Provider Demographics
NPI:1972243020
Name:DAVIS, ANDREA D (MED, LPCA)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MED, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 N TREY CT
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-8688
Mailing Address - Country:US
Mailing Address - Phone:270-272-3345
Mailing Address - Fax:
Practice Address - Street 1:104 N TREY CT
Practice Address - Street 2:
Practice Address - City:VINE GROVE
Practice Address - State:KY
Practice Address - Zip Code:40175-8688
Practice Address - Country:US
Practice Address - Phone:270-272-3345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2204076101YM0800X
KY267994101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health