Provider Demographics
NPI:1942422514
Name:ANDERSON, DANETTE (OTD)
Entity Type:Individual
Prefix:MRS
First Name:DANETTE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:MISS
Other - First Name:DANETTE
Other - Middle Name:
Other - Last Name:SUGHROUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD
Mailing Address - Street 1:615 WEST 39TH ST, SUITE A
Mailing Address - Street 2:FAMILY PHYSICAL THERAPY & SPORTS CENTER, PC
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-8049
Mailing Address - Country:US
Mailing Address - Phone:308-698-2820
Mailing Address - Fax:308-698-2822
Practice Address - Street 1:110 WEST 5TH STREET
Practice Address - Street 2:FAMILY PHYSICAL THERAPY & SPORTS CENTER, PC
Practice Address - City:LEXINGTON
Practice Address - State:NE
Practice Address - Zip Code:68850
Practice Address - Country:US
Practice Address - Phone:308-324-3700
Practice Address - Fax:308-324-5217
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1213225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025290100Medicaid
NE02334OtherBLUECROSS BLUESHIELD
NE10025290100Medicaid
NEPENDINGMedicare ID - Type UnspecifiedPENDING