Provider Demographics
NPI:1649628033
Name:DYER, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15138 CORONA DEL MAR
Mailing Address - Street 2:UNIT A
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083
Mailing Address - Country:US
Mailing Address - Phone:281-675-5675
Mailing Address - Fax:
Practice Address - Street 1:15138 CORONA DEL MAR DR UNIT A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-4308
Practice Address - Country:US
Practice Address - Phone:281-675-5675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1871044925Medicaid