Provider Demographics
NPI:1114289691
Name:THEMISTOCLEOUS, ANDREA CHRISTINE (MSED, BCBA)
Entity type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:CHRISTINE
Last Name:THEMISTOCLEOUS
Suffix:
Gender:F
Credentials:MSED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 SMITH LN
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3874
Mailing Address - Country:US
Mailing Address - Phone:917-602-4103
Mailing Address - Fax:
Practice Address - Street 1:86 SMITH LN
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3874
Practice Address - Country:US
Practice Address - Phone:917-602-4103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-07-3692103K00000X
NY1752785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst