Provider Demographics
NPI:1952942559
Name:MEDARIS, ANDREA J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:J
Last Name:MEDARIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 PARK ROW STE 302
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2053
Mailing Address - Country:US
Mailing Address - Phone:207-358-9607
Mailing Address - Fax:
Practice Address - Street 1:153 PARK ROW STE 302
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2053
Practice Address - Country:US
Practice Address - Phone:207-358-9607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1596103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical