Provider Demographics
NPI:1467949859
Name:ANDRADE, MARCELLA JOHANNA
Entity type:Individual
Prefix:
First Name:MARCELLA
Middle Name:JOHANNA
Last Name:ANDRADE
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 1:37 OLD COMMACK RD
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-3508
Mailing Address - Country:US
Mailing Address - Phone:631-507-6017
Mailing Address - Fax:
Practice Address - Street 1:1449 37TH ST STE 300
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-4380
Practice Address - Country:US
Practice Address - Phone:718-215-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP09985103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP09985OtherNYSED
NY11623792OtherBACB