Provider Demographics
NPI:1417727728
Name:ANDERSON, KELLI ELIZABETH (LMT, NDTR)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ELIZABETH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMT, NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N RECKER RD UNIT 1194
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-5552
Mailing Address - Country:US
Mailing Address - Phone:480-258-3851
Mailing Address - Fax:
Practice Address - Street 1:2150 E BROWN RD STE 4
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5249
Practice Address - Country:US
Practice Address - Phone:480-258-3851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12697225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist