Provider Demographics
NPI:1073829826
Name:ANDERSON, MARIO DONNELL (PT)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:DONNELL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:5370 CAMPBELLTON FAIRBURN RD
Practice Address - Street 2:SUITE 530
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-2296
Practice Address - Country:US
Practice Address - Phone:678-666-4146
Practice Address - Fax:678-666-4148
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT010030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist