Basic Information
| Provider Information | |||||||||
| NPI: | 1841593027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDRE | ||||||||
| FirstName: | KARINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1468 BURR ST | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068241892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035810053 | ||||||||
| FaxNumber: | 2035033183 | ||||||||
| Practice Location | |||||||||
| Address1: | 765 POST RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068246246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035810053 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2010 | ||||||||
| LastUpdateDate: | 06/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2155 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 933 | CT | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 004235918 | 05 | CT | MEDICAID |