Provider Demographics
NPI:1912577701
Name:ANDERSON, MAKAYLA
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-5390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:521 LEBANON RD
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812-5390
Practice Address - Country:US
Practice Address - Phone:803-571-1852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
SC2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer