Provider Demographics
NPI:1841926664
Name:ENNIS, ANDREA (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:ENNIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:LASKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3387 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-9519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9801 FRONTIER AVE SE
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-5200
Practice Address - Country:US
Practice Address - Phone:425-831-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64595225100000X
WAPT61374948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist