Provider Demographics
NPI: | 1780684290 |
---|---|
Name: | HUSTON, ANDRIA RENEE (PT) |
Entity Type: | Individual |
Prefix: | MS |
First Name: | ANDRIA |
Middle Name: | RENEE |
Last Name: | HUSTON |
Suffix: | |
Gender: | F |
Credentials: | PT |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 9419 KENWOOD RD |
Mailing Address - Street 2: | |
Mailing Address - City: | BLUE ASH |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45242-6811 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 513-792-0777 |
Mailing Address - Fax: | 513-792-0061 |
Practice Address - Street 1: | 9419 KENWOOD RD |
Practice Address - Street 2: | |
Practice Address - City: | BLUE ASH |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45242-6811 |
Practice Address - Country: | US |
Practice Address - Phone: | 513-792-0777 |
Practice Address - Fax: | 513-792-0061 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-07-27 |
Last Update Date: | 2022-09-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | PT6094 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | Q026880 | Medicaid | |
OH | 2507068 | Medicaid | |
OH | P00288369 | Other | MEDICARE RAILROAD |
Q21595 | Medicare UPIN | ||
OH | 000000322291 | Other | ANTHEM |
OH | 2507068 | Medicaid |