Provider Demographics
NPI:1063845766
Name:DILLARD, DE'ANDREA LR (MSM, LCSW)
Entity Type:Individual
Prefix:MS
First Name:DE'ANDREA
Middle Name:LR
Last Name:DILLARD
Suffix:
Gender:F
Credentials:MSM, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 S MAIN ST STE F
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3436
Mailing Address - Country:US
Mailing Address - Phone:203-699-6318
Mailing Address - Fax:
Practice Address - Street 1:1113 S MAIN ST STE F
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3436
Practice Address - Country:US
Practice Address - Phone:203-699-6318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-16
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
105961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060669107OtherUBH-OXFORD LIBERTY/FREEDOM PLAN WELLMORE GRP/FACILITY
CTD339210 WATERBURYOtherBEACON HEALTH STRATEGIES
CTNOT ELIGIBLEOtherMHN-TRICARE NORTH
CT060669107OtherHEALTHYCT
CTNOT ELIGIBLEOtherMHN-MANAGED HEALTH NETWORK
CT060669107OtherUBH-CONNECTICARE WELLMORE GRP/FACILITY
CT060669107OtherANTHEM BCBS OF CT -WELLMORE,INC GROUP/FACILITY CONTRACT
CTPENDINGOtherCIGNA BEHAVIORAL HEALTH
CT060669107OtherUBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY
CT12600248OtherCAQH
CTPENDINGOtherAETNA BEHAVIORAL HEALTH
CT008060102Medicaid
CT060669107OtherUNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY
CTNOT ELIGIBLEMedicare PIN