Provider Demographics
NPI:1164843520
Name:ANDRADE, DEREK ALLEN (MED, BCBA, LABA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ALLEN
Last Name:ANDRADE
Suffix:
Gender:M
Credentials:MED, BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 GREENWOOD ST STE A
Mailing Address - Street 2:SUITE B
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01607-1767
Mailing Address - Country:US
Mailing Address - Phone:508-363-0200
Mailing Address - Fax:
Practice Address - Street 1:345 GREENWOOD ST STE A
Practice Address - Street 2:SUITE B
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01607-1767
Practice Address - Country:US
Practice Address - Phone:508-363-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst