Provider Demographics
NPI:1457449233
Name:ANDERSON-RANDALL, DAWN M (PTA)
Entity Type:Individual
Prefix:MS
First Name:DAWN
Middle Name:M
Last Name:ANDERSON-RANDALL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5881 COUNTY LANE 277
Mailing Address - Street 2:
Mailing Address - City:CARL JUNCTION
Mailing Address - State:MO
Mailing Address - Zip Code:64834-8205
Mailing Address - Country:US
Mailing Address - Phone:417-623-1082
Mailing Address - Fax:
Practice Address - Street 1:1010 S MADISON ST
Practice Address - Street 2:STE F
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-2566
Practice Address - Country:US
Practice Address - Phone:417-673-0600
Practice Address - Fax:417-673-0601
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003003706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist