Provider Demographics
NPI:1548446230
Name:ANDERSON, RAQUEL LYNN (PTA)
Entity type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:RAQUEL
Other - Middle Name:LYNN
Other - Last Name:MAYCROFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3960 W MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:N MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-8671
Mailing Address - Country:US
Mailing Address - Phone:231-766-0909
Mailing Address - Fax:
Practice Address - Street 1:1212 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1879
Practice Address - Country:US
Practice Address - Phone:231-672-6940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-13
Last Update Date:2008-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 12629172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker