Provider Demographics
NPI:1295939528
Name:ANDERSON, KELLIE DEE (MPT)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:DEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1243
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-1243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5180 N PALM AVE
Practice Address - Street 2:# 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-2229
Practice Address - Country:US
Practice Address - Phone:559-244-0394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist