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General NPI Number Information
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NPI Number | 1073651865
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Entity Type | Individual
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Provider Name | ANDAESHA K'TREVA LMT
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Gender | Female
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Dates
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Enumeration Date | 02/02/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1920 CHEMEKETA ST NE
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City | SALEM
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State | OR
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Zip | 97301-4368
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Country | US
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Telephone | 503-884-7873
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6106
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City | SALEM
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State | OR
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Zip | 97304-0278
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Country | US
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Telephone | 503-884-7873
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 10539
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License Number State | OR
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