Provider Demographics
NPI:1033770912
Name:HALSTEAD, ANDREW (PT, ATC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:HALSTEAD
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9725
Mailing Address - Country:US
Mailing Address - Phone:541-929-2255
Mailing Address - Fax:
Practice Address - Street 1:732 MAIN ST
Practice Address - Street 2:
Practice Address - City:PHILOMATH
Practice Address - State:OR
Practice Address - Zip Code:97370-9725
Practice Address - Country:US
Practice Address - Phone:541-929-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-22
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63290225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist