Provider Demographics
NPI:1538239942
Name:D ANDREA, MARISA A (DC LAC)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:A
Last Name:D ANDREA
Suffix:
Gender:F
Credentials:DC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E 16TH ST
Mailing Address - Street 2:#4C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3722
Mailing Address - Country:US
Mailing Address - Phone:212-254-8833
Mailing Address - Fax:212-254-3382
Practice Address - Street 1:201 E 16TH ST
Practice Address - Street 2:#4C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3722
Practice Address - Country:US
Practice Address - Phone:212-254-8833
Practice Address - Fax:212-254-3382
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006057111N00000X
NY001436171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
X44241Medicare ID - Type Unspecified