Provider Demographics
NPI:1902370141
Name:ANDERSON, ANGELA BABB (PT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:BABB
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4063
Mailing Address - Country:US
Mailing Address - Phone:208-478-3333
Mailing Address - Fax:208-478-3329
Practice Address - Street 1:527 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4063
Practice Address - Country:US
Practice Address - Phone:208-478-3333
Practice Address - Fax:208-478-3329
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist