1255759338 NPI number — DR. ANDREA LYNN COVERMAN PSYD, CADAC, CAP

Table of content: DR. ANDREA LYNN COVERMAN PSYD, CADAC, CAP (NPI 1255759338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255759338 NPI number — DR. ANDREA LYNN COVERMAN PSYD, CADAC, CAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COVERMAN
Provider First Name:
ANDREA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD, CADAC, CAP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255759338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1475 MERCURY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRITT ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32953-3122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-252-4884
Provider Business Mailing Address Fax Number:
407-252-4884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1475 MERCURY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRITT ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32953-3122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-252-4884
Provider Business Practice Location Address Fax Number:
407-252-4884
Provider Enumeration Date:
04/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  1500 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: PY9851 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 102632600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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