=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124410485
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA MAYFIELD LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2015
-----------------------------------------------------
Last Update Date | 02/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1269 DOCTORS DR
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63640-2947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-664-1146
-----------------------------------------------------
Fax | 573-664-1149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1269 DOCTORS DR
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63640-2947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-664-1146
-----------------------------------------------------
Fax | 573-664-1149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2010042641
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------