Provider Demographics
NPI:1316380371
Name:BOSTON, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BOSTON
Suffix:
Gender:F
Credentials:
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 302
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502-0302
Mailing Address - Country:US
Mailing Address - Phone:580-483-9701
Mailing Address - Fax:
Practice Address - Street 1:5 NW 16TH ST STE 10C
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-6400
Practice Address - Country:US
Practice Address - Phone:580-280-1846
Practice Address - Fax:580-699-2304
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist