Healthcare Provider Details

I. General information

NPI: 1902665904
Provider Name (Legal Business Name): ANDREW MCINTOSH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 W RIDGE RD STE A202
ERIE PA
16506-1879
US

IV. Provider business mailing address

3939 W RIDGE RD STE A202
ERIE PA
16506-1879
US

V. Phone/Fax

Practice location:
  • Phone: 814-961-2267
  • Fax:
Mailing address:
  • Phone: 814-961-2267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPC000959
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: