Provider Demographics
NPI:1831297415
Name:MUMFORD, ANDREA WATERS (LOTR)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:WATERS
Last Name:MUMFORD
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:8080 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE # 110
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-7827
Mailing Address - Country:US
Mailing Address - Phone:225-408-7990
Mailing Address - Fax:225-408-7989
Practice Address - Street 1:8080 BLUEBONNET BLVD
Practice Address - Street 2:SUITE # 110
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-7827
Practice Address - Country:US
Practice Address - Phone:225-408-7990
Practice Address - Fax:225-408-7989
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200115225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist