Provider Demographics
NPI:1720569023
Name:ANDERSON, LORI (ATC)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S EAST ST
Mailing Address - Street 2:
Mailing Address - City:ANNAWAN
Mailing Address - State:IL
Mailing Address - Zip Code:61234-9771
Mailing Address - Country:US
Mailing Address - Phone:563-370-4086
Mailing Address - Fax:
Practice Address - Street 1:410 S EAST ST
Practice Address - Street 2:
Practice Address - City:ANNAWAN
Practice Address - State:IL
Practice Address - Zip Code:61234-9771
Practice Address - Country:US
Practice Address - Phone:563-370-4086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960027232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer