Provider Demographics
NPI:1528622594
Name:CLODFELTER, ANDREA (DPT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:CLODFELTER
Suffix:
Gender:F
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 680
Mailing Address - Street 2:
Mailing Address - City:RIDERWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21139-0680
Mailing Address - Country:US
Mailing Address - Phone:937-602-3501
Mailing Address - Fax:214-305-3399
Practice Address - Street 1:300 INTERNATIONAL CIR
Practice Address - Street 2:
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-1300
Practice Address - Country:US
Practice Address - Phone:443-275-7904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24929225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD24929Medicaid