Provider Demographics
NPI:1265855688
Name:PORTER, ANDREA MARIE
Entity Type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:MARIE
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4760 SEASCAPE WAY APT 307
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0641
Mailing Address - Country:US
Mailing Address - Phone:417-298-4431
Mailing Address - Fax:
Practice Address - Street 1:1101 STROUD AVE
Practice Address - Street 2:
Practice Address - City:KINGSBURG
Practice Address - State:CA
Practice Address - Zip Code:93631-1016
Practice Address - Country:US
Practice Address - Phone:559-897-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP636013898500222Q00000X
CA19146225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist