Provider Demographics
NPI:1376933838
Name:HERSON, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:HERSON
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 1:11908 BRISTOL MANOR CT
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-5804
Mailing Address - Country:US
Mailing Address - Phone:301-881-1394
Mailing Address - Fax:240-260-1450
Practice Address - Street 1:11908 BRISTOL MANOR CT
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-5804
Practice Address - Country:US
Practice Address - Phone:301-881-1394
Practice Address - Fax:240-260-1450
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00676252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency