Provider Demographics
NPI:1730112350
Name:BLAIS, ANDREA M (PT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:BLAIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:KNOWLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1489
Practice Address - Street 1:100 FODEN RD, WEST
Practice Address - Street 2:205
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-780-8860
Practice Address - Fax:207-523-8584
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1279225100000X
NCP141362251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4546206OtherAETNA
040510OtherANTHEM
ME267400099Medicaid
4546206OtherAETNA