Provider Demographics
NPI:1073675146
Name:ANDERSON, ILA BETH (MPT)
Entity Type:Individual
Prefix:MS
First Name:ILA
Middle Name:BETH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 AIRPORT BLVD
Mailing Address - Street 2:STE. 14
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3900
Mailing Address - Country:US
Mailing Address - Phone:304-276-4522
Mailing Address - Fax:
Practice Address - Street 1:51 SOUTHLAND DR
Practice Address - Street 2:SUITE 2300
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2244
Practice Address - Country:US
Practice Address - Phone:304-363-3167
Practice Address - Fax:304-363-1725
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist