Provider Demographics
NPI:1073366969
Name:KORALISHN, ANDREA MARIE (BS)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:KORALISHN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 COPLEY DR
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-1746
Mailing Address - Country:US
Mailing Address - Phone:978-852-1564
Mailing Address - Fax:
Practice Address - Street 1:360 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1740
Practice Address - Country:US
Practice Address - Phone:978-620-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency