Provider Demographics
NPI:1134825474
Name:ANDERSON, SHEDRACK
Entity type:Individual
Prefix:
First Name:SHEDRACK
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13601 PRESTON VIEW BLVD
Mailing Address - Street 2:SUITE.E620
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240
Mailing Address - Country:US
Mailing Address - Phone:469-885-8607
Mailing Address - Fax:
Practice Address - Street 1:13601 PRESTON VIEW BLVD
Practice Address - Street 2:SUITE.E620
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240
Practice Address - Country:US
Practice Address - Phone:469-885-8607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2243173C00000X
CA57334175F00000X
225600000X, 225A00000X, 251E00000X
TX56744171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No173C00000XOther Service ProvidersReflexologist
No175F00000XOther Service ProvidersNaturopath
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No251E00000XAgenciesHome Health