Provider Demographics
NPI:1972661650
Name:FENTON, ANDREA NOAMI (OT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NOAMI
Last Name:FENTON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:NOAMI
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:3810 SHIRE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2794
Mailing Address - Country:US
Mailing Address - Phone:832-818-4206
Mailing Address - Fax:281-403-3145
Practice Address - Street 1:3810 SHIRE VALLEY DR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-2794
Practice Address - Country:US
Practice Address - Phone:832-818-4206
Practice Address - Fax:281-403-3145
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109759225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist