Provider Demographics
NPI:1689939639
Name:BLUEL, ANDREA MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MICHELLE
Last Name:BLUEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MICHELLE
Other - Last Name:SUKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:707 S UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3027
Mailing Address - Country:US
Mailing Address - Phone:920-887-4039
Mailing Address - Fax:
Practice Address - Street 1:707 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3027
Practice Address - Country:US
Practice Address - Phone:920-887-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1789-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant