Provider Demographics
NPI:1154306439
Name:ANDERSON, FAWN BURNS (PT)
Entity type:Individual
Prefix:
First Name:FAWN
Middle Name:BURNS
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:FAWN
Other - Middle Name:MAUREEN
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 WIDGER RD
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945
Mailing Address - Country:US
Mailing Address - Phone:781-631-8250
Mailing Address - Fax:781-639-2060
Practice Address - Street 1:1 WIDGER RD
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945
Practice Address - Country:US
Practice Address - Phone:781-631-8250
Practice Address - Fax:781-639-2060
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13087225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0702099Medicaid
MAY68380OtherBCBS
MAY68380OtherBCBS