Provider Demographics
NPI:1124687215
Name:ANDERSON, ELIZABETH (R-DMT, RYT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:R-DMT, RYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:HANSCOM AFB
Mailing Address - State:MA
Mailing Address - Zip Code:01731-2651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731-2651
Practice Address - Country:US
Practice Address - Phone:850-420-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X, 225800000X
1564225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance TherapistGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist