Provider Demographics
NPI:1699460519
Name:MCCULLOUGH, ANDREA ALEXANDRA (PTA)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:ALEXANDRA
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5280 FULLER DR APT 6
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6200
Mailing Address - Country:US
Mailing Address - Phone:440-317-2770
Mailing Address - Fax:
Practice Address - Street 1:8224 MENTOR AVE STE 114
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5743
Practice Address - Country:US
Practice Address - Phone:330-867-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA012553225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant