Provider Demographics
NPI:1538919329
Name:ANDEBRHAN, MARIAH LARELL
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:LARELL
Last Name:ANDEBRHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4079 SPICEBUSH DR
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1293
Mailing Address - Country:US
Mailing Address - Phone:937-409-1309
Mailing Address - Fax:
Practice Address - Street 1:4079 SPICEBUSH DR
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-1293
Practice Address - Country:US
Practice Address - Phone:937-409-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant