Provider Demographics
NPI:1881103711
Name:VANDERVORT, ANDREA REEVES (OTR)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:REEVES
Last Name:VANDERVORT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 ROXBURGH DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2427
Mailing Address - Country:US
Mailing Address - Phone:901-896-9754
Mailing Address - Fax:
Practice Address - Street 1:2910 ROXBURGH DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2427
Practice Address - Country:US
Practice Address - Phone:901-896-9754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
006718225XP0019X
GA006718225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA006718OtherOCCUPATIONAL THERAPY