Provider Demographics
NPI:1043335979
Name:MARTELL, ANDREA M (MPT)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:M
Last Name:MARTELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17600 N 79TH AVE
Mailing Address - Street 2:APT 102
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8682
Mailing Address - Country:US
Mailing Address - Phone:304-942-5456
Mailing Address - Fax:
Practice Address - Street 1:17600 N 79TH AVE
Practice Address - Street 2:APT 102
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8682
Practice Address - Country:US
Practice Address - Phone:304-942-5456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2126314000000X
IL070012436225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility