Provider Demographics
NPI:1568043974
Name:PANICHELLA, ANDREA BREE (PTA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:BREE
Last Name:PANICHELLA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:BREE
Other - Last Name:BARTOLOTTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:2333 BIDDLE AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-4668
Mailing Address - Country:US
Mailing Address - Phone:734-246-6000
Mailing Address - Fax:
Practice Address - Street 1:2333 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4668
Practice Address - Country:US
Practice Address - Phone:734-246-8962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003760208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502003760Medicaid