Provider Demographics
NPI:1851943864
Name:D'ANDRE, NATHANIEL (LAC)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:D'ANDRE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 SEA ST APT 4
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-2800
Mailing Address - Country:US
Mailing Address - Phone:267-574-2346
Mailing Address - Fax:
Practice Address - Street 1:10000 MIDLANTIC DR
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1520
Practice Address - Country:US
Practice Address - Phone:732-982-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00733100101YM0800X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker