=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912114745
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA LUCAS FOUTZ ED.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2910 FLEETWOOD AVE SW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24015-4626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-989-6360
-----------------------------------------------------
Fax | 540-989-6360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6065 CHAGALL DR
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-5289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-725-8429
-----------------------------------------------------
Fax | 540-989-6360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------