Provider Demographics
NPI:1265630818
Name:ANDERSON, STEVEN BLAINE (MPT)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:BLAINE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 SYRINGA SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-5023
Mailing Address - Country:US
Mailing Address - Phone:801-995-1853
Mailing Address - Fax:
Practice Address - Street 1:2671 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-1833
Practice Address - Country:US
Practice Address - Phone:541-889-2221
Practice Address - Fax:541-889-3437
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-55662251X0800X
UT6588519-24012251X0800X
OR626252251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic