Provider Demographics
NPI:1114237245
Name:ANDERSON, MICHAEL TIMOTHY
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2840 ALBAZANO DR
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-7050
Mailing Address - Country:US
Mailing Address - Phone:775-232-6321
Mailing Address - Fax:
Practice Address - Street 1:255 W MOANA LN STE 104
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4942
Practice Address - Country:US
Practice Address - Phone:775-525-0270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0801819438225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner