Provider Demographics
NPI:1255640843
Name:ANDERSON, ANDI N (LMT)
Entity type:Individual
Prefix:
First Name:ANDI
Middle Name:N
Last Name:ANDERSON
Suffix:
Gender:X
Credentials:LMT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:N
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:500 N COLUMBIA RIVER HWY STE 410
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-1203
Mailing Address - Country:US
Mailing Address - Phone:503-410-5623
Mailing Address - Fax:
Practice Address - Street 1:500 N COLUMBIA RIVER HWY STE 410
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1203
Practice Address - Country:US
Practice Address - Phone:503-410-5623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17353225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist