Provider Demographics
NPI:1013118066
Name:DETAR, ANDREA RENEE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:RENEE
Last Name:DETAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:RENEE
Other - Last Name:DETAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10014 WINDRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-4364
Mailing Address - Country:US
Mailing Address - Phone:540-898-1118
Mailing Address - Fax:
Practice Address - Street 1:10014 WINDRIDGE DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-4364
Practice Address - Country:US
Practice Address - Phone:540-898-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119002336225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist