Provider Demographics
NPI:1720278351
Name:ANDERSON, KRISTEN LEIGH (PTA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 384
Mailing Address - Street 2:5744 HAWTHORNE AVE.
Mailing Address - City:ROCK HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21661-0384
Mailing Address - Country:US
Mailing Address - Phone:410-639-7561
Mailing Address - Fax:
Practice Address - Street 1:501 E CAMPUS AVE
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1670
Practice Address - Country:US
Practice Address - Phone:410-778-8307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3157225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant