Provider Demographics
NPI:1548962673
Name:BANTON, ANDREA CANDIS (LMSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:CANDIS
Last Name:BANTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 GRAND AVE FRNT DESK
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-7778
Mailing Address - Country:US
Mailing Address - Phone:718-583-9824
Mailing Address - Fax:212-979-8894
Practice Address - Street 1:463 7TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-7448
Practice Address - Country:US
Practice Address - Phone:646-483-6409
Practice Address - Fax:212-979-8894
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118790104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker