Provider Demographics
NPI:1750848438
Name:MARSH, ANDREA C (PTA)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:C
Last Name:MARSH
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 1:4438 HARTMAN RD
Mailing Address - Street 2:
Mailing Address - City:SODUS
Mailing Address - State:MI
Mailing Address - Zip Code:49126-9743
Mailing Address - Country:US
Mailing Address - Phone:815-690-8907
Mailing Address - Fax:
Practice Address - Street 1:288 PEACE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9562
Practice Address - Country:US
Practice Address - Phone:269-556-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003839225200000X
MI225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant