Provider Demographics
NPI:1417229352
Name:ANDRE, ANGELA S (PTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:S
Last Name:ANDRE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 PENSION RD
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-8400
Mailing Address - Country:US
Mailing Address - Phone:732-792-9996
Mailing Address - Fax:732-792-2137
Practice Address - Street 1:104 PENSION RD
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8400
Practice Address - Country:US
Practice Address - Phone:732-792-9996
Practice Address - Fax:732-792-2137
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00249300225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant