Provider Demographics
NPI:1104832245
Name:STACHURSKI, ANDREA (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:STACHURSKI
Suffix:
Gender:F
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:3519 N GREEN RIVER RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-1347
Practice Address - Country:US
Practice Address - Phone:812-473-7253
Practice Address - Fax:812-473-7264
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009003A225100000X
KY005220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00457674Medicare UPIN
IN216070EMedicare PIN
IN198850FMedicare PIN