Provider Demographics
NPI:1831172477
Name:POWELL, ANDREA T (PT)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:T
Last Name:POWELL
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:PO BOX 5982
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23471-0982
Mailing Address - Country:US
Mailing Address - Phone:757-474-7490
Mailing Address - Fax:757-474-7931
Practice Address - Street 1:1444 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464
Practice Address - Country:US
Practice Address - Phone:757-474-7490
Practice Address - Fax:757-474-7931
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704009537101YM0800X
VA2305006303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010378079Medicaid
VA010378354Medicaid
VA010378621Medicaid
VA010378001Medicaid
VA010378117Medicaid
VA010378630Medicaid
VA010378354Medicaid