Provider Demographics
NPI:1124570767
Name:ANDERSON, MICHAEL BRENTON (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRENTON
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:7721 AIRPORT BLVD STE E120
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-5052
Practice Address - Country:US
Practice Address - Phone:251-631-3680
Practice Address - Fax:251-631-3681
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH8121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPTH8121OtherSTATE LICENSE