Provider Demographics
NPI:1821455197
Name:ANDERSON, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLE
Other - Middle Name:VERLANDER
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 7066
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-7066
Mailing Address - Country:US
Mailing Address - Phone:228-354-9460
Mailing Address - Fax:228-354-9462
Practice Address - Street 1:4387 LEISURE TIME DR
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3242
Practice Address - Country:US
Practice Address - Phone:228-255-3533
Practice Address - Fax:228-255-3536
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist