Provider Demographics
NPI:1073651865
Name:K'TREVA, ANDAESHA (LMT)
Entity Type:Individual
Prefix:
First Name:ANDAESHA
Middle Name:
Last Name:K'TREVA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6106
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-0278
Mailing Address - Country:US
Mailing Address - Phone:503-884-7873
Mailing Address - Fax:
Practice Address - Street 1:1920 CHEMEKETA ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4368
Practice Address - Country:US
Practice Address - Phone:503-884-7873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10539174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist