Provider Demographics
NPI:1518440940
Name:TAYLOR, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:TAYLOR
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 1:61 TITUS COAN RD
Mailing Address - Street 2:
Mailing Address - City:KILLINGWORTH
Mailing Address - State:CT
Mailing Address - Zip Code:06419-1446
Mailing Address - Country:US
Mailing Address - Phone:203-215-5356
Mailing Address - Fax:
Practice Address - Street 1:61 TITUS COAN RD
Practice Address - Street 2:
Practice Address - City:KILLINGWORTH
Practice Address - State:CT
Practice Address - Zip Code:06419-1446
Practice Address - Country:US
Practice Address - Phone:203-215-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006718225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist