Provider Demographics
NPI:1699662395
Name:ANDERSON, MIKE JR
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7608 HEARTHSIDE WAY UNIT 2027
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-7609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7608 HEARTHSIDE WAY UNIT 2027
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-7609
Practice Address - Country:US
Practice Address - Phone:240-644-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM06875225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist