Provider Demographics
NPI:1043312002
Name:ANDERSON, GWENDA LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:GWENDA
Middle Name:LYNN
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 1:25 MAIN ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:SMITHFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:15478-8943
Mailing Address - Country:US
Mailing Address - Phone:724-569-4404
Mailing Address - Fax:724-569-4406
Practice Address - Street 1:25 MAIN ST
Practice Address - Street 2:SUITE 7
Practice Address - City:SMITHFIELD
Practice Address - State:PA
Practice Address - Zip Code:15478-8943
Practice Address - Country:US
Practice Address - Phone:724-569-4404
Practice Address - Fax:724-569-4406
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE006914225200000X
WV000881225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant