Provider Demographics
NPI:1770632440
Name:STEVENS, ANDREA L (LIC AC)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:L
Last Name:STEVENS
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MAIN ST
Mailing Address - Street 2:#324
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-3509
Mailing Address - Country:US
Mailing Address - Phone:207-710-8089
Mailing Address - Fax:
Practice Address - Street 1:35 WESTERN AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-7366
Practice Address - Country:US
Practice Address - Phone:207-710-8089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME431821171100000X
MA226517171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist