MEDICARE: CARLEY MICHELLE ANDERSON PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	NONE
2	225100000X	Physical Therapist	2162102	TX

General Provider Information

NPI Number	:	1114145331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLEY MICHELLE ANDERSON PTA

Provider Business Mailing Address
First Line	:	12880 NS 3590
Second Line	:
City	:	WEWOKA
State	:	OK
Zip	:	74884-5402
Country	:	US
Telephone Number	:	405-398-4761
Fax Number	:

Provider Business Practice Location Address
First Line	:	3401 AMADOR DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-2227
Country	:	US
Telephone Number	:	682-204-0853
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/14/2021

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Directions to “ CARLEY MICHELLE ANDERSON PTA” Practice Location

Language	Start Address	Practice Location

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