Provider Demographics
NPI:1114145331
Name:ANDERSON, CARLEY MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:CARLEY
Middle Name:MICHELLE
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 1:12880 NS 3590
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-5402
Mailing Address - Country:US
Mailing Address - Phone:405-398-4761
Mailing Address - Fax:
Practice Address - Street 1:3401 AMADOR DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-2227
Practice Address - Country:US
Practice Address - Phone:682-204-0853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE101YM0800X
TX2162102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health