Provider Demographics
NPI:1568412369
Name:ANDERSON, CECIL M III (PT)
Entity Type:Individual
Prefix:MR
First Name:CECIL
Middle Name:M
Last Name:ANDERSON
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 WINN WAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1735
Mailing Address - Country:US
Mailing Address - Phone:404-297-9315
Mailing Address - Fax:
Practice Address - Street 1:487 WINN WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1735
Practice Address - Country:US
Practice Address - Phone:404-297-9315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBBCBMedicare ID - Type Unspecified