Provider Demographics
NPI:1104489772
Name:ANDRE, ALEXANDER (DPT)
Entity type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:ANDRE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 724557
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31139-1557
Mailing Address - Country:US
Mailing Address - Phone:757-873-4115
Mailing Address - Fax:757-873-9619
Practice Address - Street 1:204 MILL ST NE STE E
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4500
Practice Address - Country:US
Practice Address - Phone:703-991-8156
Practice Address - Fax:703-991-8158
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305212621OtherVA PT LICENSE