Provider Demographics
NPI:1417606716
Name:ANDERSON, BRETT AUSTIN
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:AUSTIN
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 1:1614 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-2087
Mailing Address - Country:US
Mailing Address - Phone:630-749-0210
Mailing Address - Fax:
Practice Address - Street 1:8414 NAAB RD STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1972
Practice Address - Country:US
Practice Address - Phone:317-338-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program