Healthcare Provider Details

I. General information

NPI: 1013068840
Provider Name (Legal Business Name): ANDREA ROBERTA DEL GRANDE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 COVE RD
BROOKINGS OR
97415-2520
US

IV. Provider business mailing address

3587 HEATHROW WAY
MEDFORD OR
97504-4004
US

V. Phone/Fax

Practice location:
  • Phone: 541-469-0222
  • Fax: 541-469-0228
Mailing address:
  • Phone: 541-858-8170
  • Fax: 541-858-8167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC 1328
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC4401
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: