Provider Demographics
NPI:1992404032
Name:LIVELY, ANDREW (PT, DPT, MS)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:LIVELY
Suffix:
Gender:M
Credentials:PT, DPT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SALT ROCK
Mailing Address - State:WV
Mailing Address - Zip Code:25559-9777
Mailing Address - Country:US
Mailing Address - Phone:304-544-7968
Mailing Address - Fax:
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-526-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV004323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist