Provider Demographics
NPI:1962786970
Name:POMAKIS, ANDREA (LCSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:POMAKIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-4110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1329 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-4110
Practice Address - Country:US
Practice Address - Phone:207-799-4160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1198011041C0700X
MELC13032101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1962786970OtherNON BILLING PROVIDER
03021982OtherBEHAVIORAL HEALTH