Provider Demographics
NPI:1598379307
Name:VIDUSIC, ANDREA LOUISE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LOUISE
Last Name:VIDUSIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23694 ANDREW BLVD
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48134-9318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23694 ANDREW BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN
Practice Address - State:MI
Practice Address - Zip Code:48134-9318
Practice Address - Country:US
Practice Address - Phone:734-775-6585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer