Provider Demographics
NPI:1861036428
Name:BACON, ANDREA
Entity Type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:
Last Name:BACON
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 1:61 RICHARDS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1928
Mailing Address - Country:US
Mailing Address - Phone:508-330-1440
Mailing Address - Fax:
Practice Address - Street 1:400 WASHINGTON ST STE 303
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4768
Practice Address - Country:US
Practice Address - Phone:781-843-3683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor