Provider Demographics
NPI:1114051984
Name:DERSTINE, R. ANDREW (LCSW)
Entity Type:Individual
Prefix:MR
First Name:R.
Middle Name:ANDREW
Last Name:DERSTINE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 731
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009
Mailing Address - Country:US
Mailing Address - Phone:207-647-2400
Mailing Address - Fax:207-647-2400
Practice Address - Street 1:236A PORTLAND RD
Practice Address - Street 2:
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009
Practice Address - Country:US
Practice Address - Phone:207-647-2400
Practice Address - Fax:207-647-2400
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health