Provider Demographics
NPI:1821376153
Name:ANDERSON, JOHNATHON EUGENE (LMT)
Entity Type:Individual
Prefix:MR
First Name:JOHNATHON
Middle Name:EUGENE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06057-2026
Mailing Address - Country:US
Mailing Address - Phone:860-605-3312
Mailing Address - Fax:
Practice Address - Street 1:1606 HOPMEADOW ST
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-1448
Practice Address - Country:US
Practice Address - Phone:860-806-1509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03-059546225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist