Provider Demographics
NPI:1629846472
Name:ANDERSON, MAXWELL TYLER (ATC/LAT, OPE-C)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:TYLER
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:ATC/LAT, OPE-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 CROMPOND RD BLDG E
Mailing Address - Street 2:
Mailing Address - City:CORTLANDT MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10567-4146
Mailing Address - Country:US
Mailing Address - Phone:914-233-3022
Mailing Address - Fax:914-402-1194
Practice Address - Street 1:1985 CROMPOND RD BLDG E
Practice Address - Street 2:
Practice Address - City:CORTLANDT MANOR
Practice Address - State:NY
Practice Address - Zip Code:10567-4146
Practice Address - Country:US
Practice Address - Phone:914-233-3022
Practice Address - Fax:914-402-1194
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0031852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer