Provider Demographics
NPI:1497908776
Name:ANDERSON, CARRIE LEE (ATC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12304 N 1900TH ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:IL
Mailing Address - Zip Code:62441-4805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:567 N 5TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-1903
Practice Address - Country:US
Practice Address - Phone:217-369-2216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-0026202255A2300X
IN36001697A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer