Provider Demographics
NPI:1790346757
Name:ANDERSEN, CALLIE (PTA)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 N BROOKMOORE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2024
Mailing Address - Country:US
Mailing Address - Phone:717-839-2188
Mailing Address - Fax:717-565-1104
Practice Address - Street 1:1211 S GLOSTER ST STE C
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6535
Practice Address - Country:US
Practice Address - Phone:662-432-1523
Practice Address - Fax:662-432-1528
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA5714225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant