Provider Demographics
NPI:1154104420
Name:VANDEMARK, ANDREANNA PATRICIA
Entity type:Individual
Prefix:
First Name:ANDREANNA
Middle Name:PATRICIA
Last Name:VANDEMARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:ANDREANNA
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:195 FORE RIVER PKWY STE 150
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2782
Mailing Address - Country:US
Mailing Address - Phone:207-649-1764
Mailing Address - Fax:
Practice Address - Street 1:195 FORE RIVER PKWY STE 150
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2782
Practice Address - Country:US
Practice Address - Phone:207-879-3526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-18
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC22493101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health