Provider Demographics
NPI:1902620222
Name:ANDRE, PHILOMENE I
Entity type:Individual
Prefix:
First Name:PHILOMENE
Middle Name:
Last Name:ANDRE
Suffix:I
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 1:4168 LAKE MIST DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5112
Mailing Address - Country:US
Mailing Address - Phone:978-876-6451
Mailing Address - Fax:
Practice Address - Street 1:4168 LAKE MIST DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5112
Practice Address - Country:US
Practice Address - Phone:978-876-6451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician