Provider Demographics
NPI:1619416161
Name:ANDRE, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:ANDRE
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 1:32 LANSDOWNE STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:774-297-1148
Mailing Address - Fax:
Practice Address - Street 1:103 COMMERCIAL STREET
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:TERRITORY
Practice Address - Zip Code:02301
Practice Address - Country:UM
Practice Address - Phone:508-521-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health