Provider Demographics
NPI:1679507263
Name:IYEGHA, ANDREA LAUREN (MA, LICSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LAUREN
Last Name:IYEGHA
Suffix:
Gender:F
Credentials:MA, LICSW
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LAUREN
Other - Last Name:BERGLUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:1900 SILVER LAKE RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1786
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:651-628-0411
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17243104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker