Provider Demographics
NPI:1902862378
Name:ANDERSON, LETECIA (PT)
Entity Type:Individual
Prefix:MS
First Name:LETECIA
Middle Name:
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 1:6630 S MCCARRAN BLVD
Mailing Address - Street 2:SUITE A4
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6158
Mailing Address - Country:US
Mailing Address - Phone:775-828-2880
Mailing Address - Fax:775-828-2889
Practice Address - Street 1:6630 S MCCARRAN BLVD
Practice Address - Street 2:SUITE A4
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6158
Practice Address - Country:US
Practice Address - Phone:775-828-2866
Practice Address - Fax:775-828-2891
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500695Medicaid
NV11426111OtherCAQH