Provider Demographics
NPI:1699897785
Name:POORE, ANDREA RENEE
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:RENEE
Last Name:POORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-2731
Mailing Address - Country:US
Mailing Address - Phone:765-644-0500
Mailing Address - Fax:765-378-9019
Practice Address - Street 1:310 E 7TH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-2731
Practice Address - Country:US
Practice Address - Phone:765-644-0500
Practice Address - Fax:765-378-9019
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
373H00000X
IN373H00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist