Provider Demographics
NPI:1639953813
Name:ANDERSON, KAITLYN (PT)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 S LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1519
Mailing Address - Country:US
Mailing Address - Phone:806-771-8008
Mailing Address - Fax:
Practice Address - Street 1:2241 PEGGY LN STE C
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-5709
Practice Address - Country:US
Practice Address - Phone:972-272-9643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1379172225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8UU723OtherBCBS