Provider Demographics
NPI:1790327369
Name:ANDERSON, DUSTY (PTA, CSCS, BMS)
Entity Type:Individual
Prefix:
First Name:DUSTY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PTA, CSCS, BMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6151 COUNTY ROAD 124
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-4837
Mailing Address - Country:US
Mailing Address - Phone:972-645-1833
Mailing Address - Fax:972-645-1834
Practice Address - Street 1:6151 COUNTY ROAD 124
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-4837
Practice Address - Country:US
Practice Address - Phone:972-645-1833
Practice Address - Fax:972-645-1834
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2062098225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2062098OtherPROFESSIONAL LICENSE