Provider Demographics
NPI:1205159159
Name:LEGAULT, ANDREA M (PT)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:M
Last Name:LEGAULT
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 1:1620 APPERSON DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7217
Mailing Address - Country:US
Mailing Address - Phone:540-444-0291
Mailing Address - Fax:
Practice Address - Street 1:1620 APPERSON DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7217
Practice Address - Country:US
Practice Address - Phone:540-444-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-07
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203637225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist