Provider Demographics
NPI:1902335060
Name:DATTADEEN, ANDREA JOYCE (LLPC)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:JOYCE
Last Name:DATTADEEN
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4123
Mailing Address - Country:US
Mailing Address - Phone:616-510-8291
Mailing Address - Fax:
Practice Address - Street 1:2400 EASTERN AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3632
Practice Address - Country:US
Practice Address - Phone:616-988-3433
Practice Address - Fax:313-899-7087
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015974101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401015974OtherSTATE THERAPIST LICENSE