Provider Demographics
NPI:1548295496
Name:ANDERSON, KATHLEEN MARIE (PT)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:ANDERSON
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 1:177 LEEDS LN
Mailing Address - Street 2:
Mailing Address - City:KING
Mailing Address - State:NC
Mailing Address - Zip Code:27021-8800
Mailing Address - Country:US
Mailing Address - Phone:336-983-7091
Mailing Address - Fax:336-983-4915
Practice Address - Street 1:320 E KING ST
Practice Address - Street 2:SUITE B
Practice Address - City:KING
Practice Address - State:NC
Practice Address - Zip Code:27021-9162
Practice Address - Country:US
Practice Address - Phone:336-918-7476
Practice Address - Fax:336-983-4915
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2598225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC49399OtherPHYSICAL THERAPY
NC079TOOtherPHYSICAL THERAPY
NCD7126OtherPHYSICAL THERAPY
NC2505350Medicare ID - Type Unspecified
NC49399OtherPHYSICAL THERAPY