Basic Information
| Provider Information | |||||||||
| NPI: | 1447390679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREES | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5982 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234710982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572285201 | ||||||||
| FaxNumber: | 7574816175 | ||||||||
| Practice Location | |||||||||
| Address1: | 762 INDEPENDENCE BLVD | ||||||||
| Address2: | #772 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234556200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572285201 | ||||||||
| FaxNumber: | 7574816175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 03/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305005069 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1447390679 | 05 | VA | MEDICAID |