Healthcare Provider Details

I. General information

NPI: 1124104484
Provider Name (Legal Business Name): ANDREW SHANNON NEFF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4139 BEACHMONT DR.
CLINTON WA
98236-8411
US

IV. Provider business mailing address

4139 BEACHMONT DR.
CLINTON WA
98236-8411
US

V. Phone/Fax

Practice location:
  • Phone: 360-341-1443
  • Fax:
Mailing address:
  • Phone: 360-341-1443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberRC00055231
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: