Provider Demographics
NPI:1669897005
Name:ANDERSON, MAURA ELLEN (LMT)
Entity type:Individual
Prefix:MS
First Name:MAURA
Middle Name:ELLEN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 MERRICK RD
Mailing Address - Street 2:SUITE # 201
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3338
Mailing Address - Country:US
Mailing Address - Phone:516-384-4898
Mailing Address - Fax:
Practice Address - Street 1:865 MERRICK RD
Practice Address - Street 2:SUITE # 201
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3338
Practice Address - Country:US
Practice Address - Phone:516-384-4898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026741225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist