Provider Demographics
NPI:1518099381
Name:LIBBY, ANDREA (PTA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LIBBY
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 1:4975 MORRIS AVE
Mailing Address - Street 2:APT 1341
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6607
Mailing Address - Country:US
Mailing Address - Phone:214-517-9095
Mailing Address - Fax:
Practice Address - Street 1:2908 E TRINITY MILLS RD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-2318
Practice Address - Country:US
Practice Address - Phone:972-417-9999
Practice Address - Fax:972-417-9906
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2051078225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant