Provider Demographics
NPI:1053820050
Name:BRAGDON, ANDREA (MS)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BRAGDON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MOULTRIE LANDING BLVD APT 6106
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5984
Mailing Address - Country:US
Mailing Address - Phone:207-844-0503
Mailing Address - Fax:
Practice Address - Street 1:4651 SALISBURY RD STE 400
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6187
Practice Address - Country:US
Practice Address - Phone:646-941-7645
Practice Address - Fax:929-596-7897
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-22
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18130101YM0800X
MECC6599101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional