Provider Demographics
NPI:1326657628
Name:JUAREZ, ANDREA (OTD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E SUNSHINE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1143
Mailing Address - Country:US
Mailing Address - Phone:417-889-4800
Mailing Address - Fax:270-215-4834
Practice Address - Street 1:1301 E SUNSHINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1143
Practice Address - Country:US
Practice Address - Phone:417-889-4800
Practice Address - Fax:270-215-4834
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020023044225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020023044OtherSTATE LICENSE