Provider Demographics
NPI:1497001010
Name:PORTER, ANDREA LEIGH (PTA)
Entity Type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:LEIGH
Last Name:PORTER
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 1:353 26TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-5087
Mailing Address - Country:US
Mailing Address - Phone:330-933-8968
Mailing Address - Fax:
Practice Address - Street 1:4645 BELPAR ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3602
Practice Address - Country:US
Practice Address - Phone:330-493-4210
Practice Address - Fax:330-493-4744
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2012-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA-08525225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant