Provider Demographics
NPI:1629016167
Name:DEBOER, ANDREA ANTOINETTE (MFT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:ANTOINETTE
Last Name:DEBOER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:ANTOINETTE
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:678 MAIN ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3615
Mailing Address - Country:US
Mailing Address - Phone:203-315-1028
Mailing Address - Fax:203-315-4865
Practice Address - Street 1:678 MAIN ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3615
Practice Address - Country:US
Practice Address - Phone:203-315-1028
Practice Address - Fax:203-315-4865
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 2151106H00000X
CT000720106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist