Provider Demographics
NPI:1578038402
Name:BAHAN, ANDREA (MPT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BAHAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 BAY POINTE DR
Mailing Address - Street 2:
Mailing Address - City:FREEBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62243-2737
Mailing Address - Country:US
Mailing Address - Phone:618-567-0413
Mailing Address - Fax:
Practice Address - Street 1:1 PERRYMAN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IL
Practice Address - Zip Code:62254-1356
Practice Address - Country:US
Practice Address - Phone:618-537-6165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012532225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist