1164613402 NPI number — MRS. ANDREA MARIE HOLLERAN LICSW

Table of content: MRS. ANDREA MARIE HOLLERAN LICSW (NPI 1164613402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164613402 NPI number — MRS. ANDREA MARIE HOLLERAN LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLERAN
Provider First Name:
ANDREA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOPRESTI
Provider Other First Name:
ANDREA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164613402
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BEACON HEALTH OPTIONS
Provider Second Line Business Mailing Address:
500 UNICORN PARK DRIVE
Provider Business Mailing Address City Name:
WOBURN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-335-9912
Provider Business Mailing Address Fax Number:
781-994-7668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BEACON HEALTH OPTIONS
Provider Second Line Business Practice Location Address:
500 UNICORN PARK DRIVE
Provider Business Practice Location Address City Name:
WOBURN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-335-9912
Provider Business Practice Location Address Fax Number:
781-994-7668
Provider Enumeration Date:
08/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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