Provider Demographics
NPI:1104042431
Name:HEDAYAT-HARRIS, ANDIEA (PHD)
Entity Type:Individual
Prefix:
First Name:ANDIEA
Middle Name:
Last Name:HEDAYAT-HARRIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ANDIEA
Other - Middle Name:
Other - Last Name:HEDAYAT-HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2215 NORTH CENTRAL ROAD APT 4G
Mailing Address - Street 2:FORT LEE
Mailing Address - City:NEW JERSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-0702
Mailing Address - Country:US
Mailing Address - Phone:201-585-8720
Mailing Address - Fax:
Practice Address - Street 1:2215 N CENTRAL RD
Practice Address - Street 2:APT. 4G
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-7551
Practice Address - Country:US
Practice Address - Phone:201-585-8720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012882-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02423747Medicaid
NY02423747Medicaid