Provider Demographics
NPI:1659944098
Name:ANDERSON, AMY ELAINE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELAINE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W WALLEN RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2225
Mailing Address - Country:US
Mailing Address - Phone:260-615-8219
Mailing Address - Fax:
Practice Address - Street 1:14425 LEO RD
Practice Address - Street 2:
Practice Address - City:LEO
Practice Address - State:IN
Practice Address - Zip Code:46765-9407
Practice Address - Country:US
Practice Address - Phone:260-615-8219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21706349225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty