Provider Demographics
NPI:1982939179
Name:ICENOGLE, ANDREA RAE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:RAE
Last Name:ICENOGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 SW 175TH PL
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7909
Mailing Address - Country:US
Mailing Address - Phone:503-997-8954
Mailing Address - Fax:
Practice Address - Street 1:663 SW 175TH PL
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7909
Practice Address - Country:US
Practice Address - Phone:503-997-8954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR241705225X00000X
AZ4434225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist