Individual
ANDREA K-P FAFFORD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
6501 3RD AVE, KENOSHA, WI 53143-5111
(262) 914-6540
(262) 997-1061
Mailing address
3708 16TH AVE, KENOSHA, WI 53140-2441
(414) 218-3413
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
7912-123
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100085186
—
WI
Enumeration date
08/27/2012
Last updated
07/13/2020
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