Provider Demographics
NPI:1245990738
Name:CRUCILLO, ANDREANA RAINA ROSA TRINIDAD (PT)
Entity type:Individual
Prefix:
First Name:ANDREANA RAINA ROSA
Middle Name:TRINIDAD
Last Name:CRUCILLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13549 ITHACA CRESENT LANE
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583
Mailing Address - Country:US
Mailing Address - Phone:956-990-8349
Mailing Address - Fax:
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2399
Practice Address - Country:US
Practice Address - Phone:832-824-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-23
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1350377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist