Healthcare Provider Details

I. General information

NPI: 1780531004
Provider Name (Legal Business Name): ANDREW HAVERSTICK LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 03/16/2026
Certification Date: 03/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 N MADISON AVE
LOS ANGELES CA
90004-3504
US

IV. Provider business mailing address

340 N MADISON AVE
LOS ANGELES CA
90004-3504
US

V. Phone/Fax

Practice location:
  • Phone: 573-416-3428
  • Fax:
Mailing address:
  • Phone: 573-416-3428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number22193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: