Basic Information
| Provider Information | |||||||||
| NPI: | 1790031045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VERGNE | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HINOJOSA | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 44 LEAHY RD | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023022601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085138976 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 66 TROY ST | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027203023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086765708 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2012 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.