Provider Demographics
NPI:1427392067
Name:ANDERSON, TYRA JAYDE (OTR)
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:JAYDE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 WALTER REED BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-5726
Mailing Address - Country:US
Mailing Address - Phone:972-487-5570
Mailing Address - Fax:972-487-5098
Practice Address - Street 1:705 WALTER REED BLVD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-5726
Practice Address - Country:US
Practice Address - Phone:972-487-5098
Practice Address - Fax:972-487-5098
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101712225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist