Provider Demographics
NPI:1407213879
Name:ANDERSON, CAROLINE MAE (ATC, PTA)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:MAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3564 HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:VELVA
Mailing Address - State:ND
Mailing Address - Zip Code:58790-9172
Mailing Address - Country:US
Mailing Address - Phone:701-338-2984
Mailing Address - Fax:
Practice Address - Street 1:1 BURDICK EXPY W
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4406
Practice Address - Country:US
Practice Address - Phone:701-338-2984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND0872225200000X
ND076-902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer