Provider Demographics
NPI:1528817210
Name:ANDERSON, MIKAILI (PT, DPT)
Entity type:Individual
Prefix:
First Name:MIKAILI
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 ARLINGTON CT
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-3789
Mailing Address - Country:US
Mailing Address - Phone:201-546-2627
Mailing Address - Fax:
Practice Address - Street 1:3721 NEW MACLAND RD STE 530
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-2089
Practice Address - Country:US
Practice Address - Phone:470-632-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT017091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist