Provider Demographics
NPI:1700074192
Name:ANDROSTIC, MICHELLE L (OT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:ANDROSTIC
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 INNOVATION DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-8096
Mailing Address - Country:US
Mailing Address - Phone:724-343-4060
Mailing Address - Fax:724-343-4069
Practice Address - Street 1:8 OLD WILLIAM PENN HWY
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15717-7855
Practice Address - Country:US
Practice Address - Phone:724-459-6111
Practice Address - Fax:724-459-0355
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC004824L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA396749Medicare PIN