Provider Demographics
NPI:1003515875
Name:ANDERSON, KATIE SUE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:SUE
Last Name:ANDERSON
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 1:1009 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-5705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 N SHIAWASSEE ST STE A
Practice Address - Street 2:
Practice Address - City:CORUNNA
Practice Address - State:MI
Practice Address - Zip Code:48817-1444
Practice Address - Country:US
Practice Address - Phone:989-928-3566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist