Provider Demographics
NPI:1427809383
Name:ANDOROUS, MARIAM (PT)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:ANDOROUS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 WHISTLER CREEK DR APT 411
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-8231
Mailing Address - Country:US
Mailing Address - Phone:682-414-6158
Mailing Address - Fax:
Practice Address - Street 1:800 N JIM WRIGHT FWY # 2
Practice Address - Street 2:
Practice Address - City:WHITE SETTLEMENT
Practice Address - State:TX
Practice Address - Zip Code:76108-1068
Practice Address - Country:US
Practice Address - Phone:682-414-6158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1387735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist