MEDICARE: MYLISSA COURTNEY ANDERSON DPT

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	225100000X	Physical Therapist	PT295733	CA

General Provider Information

NPI Number	:	1679044903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYLISSA COURTNEY ANDERSON DPT

Provider Business Mailing Address
First Line	:	3421 ARLINGTON AVE STE 105
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3201
Country	:	US
Telephone Number	:	951-684-2865
Fax Number	:

Provider Business Practice Location Address
First Line	:	3421 ARLINGTON AVE STE 105
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3201
Country	:	US
Telephone Number	:	951-684-2865
Fax Number	:

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

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	12/16/2018

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