Provider Demographics
NPI:1396889747
Name:LEGG, ANDREA MICHELLE (PT, DPT, MED, ATC)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:MICHELLE
Last Name:LEGG
Suffix:
Gender:F
Credentials:PT, DPT, MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 ELLINGTON CT
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-2058
Mailing Address - Country:US
Mailing Address - Phone:315-787-4570
Mailing Address - Fax:
Practice Address - Street 1:4107 W GENESEE ST STE 300
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-1952
Practice Address - Country:US
Practice Address - Phone:315-635-5000
Practice Address - Fax:315-492-1203
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0201023212255A2300X
NY035863225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer