Provider Demographics
NPI:1568960797
Name:ANDERSON, CHARLIE (DPT)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 ROCK MERRITT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:
Practice Address - Street 1:39575 W 10 MILE RD STE 201
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375
Practice Address - Country:US
Practice Address - Phone:248-516-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010185242251S0007X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports