Provider Demographics
NPI:1326747122
Name:ANDERSON, CYLE WILLIAM (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:CYLE
Middle Name:WILLIAM
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 W SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62522-2741
Mailing Address - Country:US
Mailing Address - Phone:217-972-1219
Mailing Address - Fax:
Practice Address - Street 1:1750 E LAKE SHORE DR # LL1
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3803
Practice Address - Country:US
Practice Address - Phone:217-464-1459
Practice Address - Fax:217-464-1476
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0031252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer