Provider Demographics
NPI:1275914343
Name:BURNHAM, ANDREA GAYE (LMT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:GAYE
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-5641
Mailing Address - Country:US
Mailing Address - Phone:503-635-1236
Mailing Address - Fax:
Practice Address - Street 1:1703 HUDSON ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2912
Practice Address - Country:US
Practice Address - Phone:503-765-6673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21470225700000X
WAMA61065984225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist