Individual
ANDREA RAE ICENOGLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
663 SW 175TH PL, BEAVERTON, OR 97006-7909
(503) 997-8954
Mailing address
663 SW 175TH PL, BEAVERTON, OR 97006-7909
(503) 997-8954
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
241705
OR
225X00000X
Occupational Therapist
4434
AZ
Other
Enumeration date
10/06/2009
Last updated
10/06/2009
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