Provider Demographics
NPI:1689920399
Name:DEYLOFF, ANDREA (PTA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DEYLOFF
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 1:6300 MONTGOMERY BLVD NE APT 101
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1428
Mailing Address - Country:US
Mailing Address - Phone:505-550-3967
Mailing Address - Fax:
Practice Address - Street 1:505 ELM ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2500
Practice Address - Country:US
Practice Address - Phone:505-506-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0884225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant