Provider Demographics
NPI:1174148316
Name:DEWAELE, ANDREA ELIZABETH (LPTA)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:ELIZABETH
Last Name:DEWAELE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:ELIZABETH
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:358 KERBY RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3143
Mailing Address - Country:US
Mailing Address - Phone:313-574-5905
Mailing Address - Fax:
Practice Address - Street 1:25375 KELLY RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4960
Practice Address - Country:US
Practice Address - Phone:586-773-6022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-13
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000541225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant