Provider Demographics
NPI:1932657905
Name:ANDERSON, LILLIAN (RBT)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-8611
Mailing Address - Country:US
Mailing Address - Phone:850-586-4093
Mailing Address - Fax:
Practice Address - Street 1:4015 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-8611
Practice Address - Country:US
Practice Address - Phone:850-586-4093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL#RBT-15-09308247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other