Provider Demographics
NPI:1477000883
Name:ANDERSON, MARSHALL (MS LAT ATC)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MS LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 GENESIS DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8650
Mailing Address - Country:US
Mailing Address - Phone:214-912-4130
Mailing Address - Fax:
Practice Address - Street 1:101 GOPHER BOULEVARD
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051
Practice Address - Country:US
Practice Address - Phone:972-809-5762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT20692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer