Healthcare Provider Details

I. General information

NPI: 1255689022
Provider Name (Legal Business Name): ANDREA K-P FAFFORD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDREA K PERATT

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 3RD AVE
KENOSHA WI
53143-5111
US

IV. Provider business mailing address

3708 16TH AVE
KENOSHA WI
53140-2441
US

V. Phone/Fax

Practice location:
  • Phone: 262-914-6540
  • Fax: 262-997-1061
Mailing address:
  • Phone: 414-218-3413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7912-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: