Provider Demographics
NPI:1407081755
Name:KOUROS, ANDREA A
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:A
Last Name:KOUROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDI
Other - Middle Name:
Other - Last Name:KOUROS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:12 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-775-4263
Mailing Address - Fax:
Practice Address - Street 1:12 ATLANTIC PL
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2316
Practice Address - Country:US
Practice Address - Phone:207-775-4263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist