Healthcare Provider Details

I. General information

NPI: 1376755561
Provider Name (Legal Business Name): JOAN MARIE ANDERSON CTRS, RTC, ACC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3853 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

3853 ROSECRANS STREET
SAN DIEGO CA
92110-3115
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8241
  • Fax:
Mailing address:
  • Phone: 619-692-8241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number2177-T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: