Provider Demographics
NPI:1073895454
Name:ANDERSON, ASHLEY (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 N STATE ROAD 29
Mailing Address - Street 2:
Mailing Address - City:MICHIGANTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46057-9616
Mailing Address - Country:US
Mailing Address - Phone:765-249-2255
Mailing Address - Fax:
Practice Address - Street 1:815 N STATE ROAD 29
Practice Address - Street 2:
Practice Address - City:MICHIGANTOWN
Practice Address - State:IN
Practice Address - Zip Code:46057-9616
Practice Address - Country:US
Practice Address - Phone:765-249-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001822A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer