Provider Demographics
NPI:1952548158
Name:MACEDON, ANDRE ALEXANDER
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:ALEXANDER
Last Name:MACEDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1771
Mailing Address - Country:US
Mailing Address - Phone:214-703-5115
Mailing Address - Fax:
Practice Address - Street 1:1614 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-1771
Practice Address - Country:US
Practice Address - Phone:214-703-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-10
Last Update Date:2009-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities