=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417381872
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE KELLY ANDREOU PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2013
-----------------------------------------------------
Last Update Date | 08/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1655 PALM BEACH LAKES BLVD STE 300
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33401-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-612-6056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4651 PINEMORE LN
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33463-6990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-649-4987
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY6621
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------