Healthcare Provider Details

I. General information

NPI: 1023279080
Provider Name (Legal Business Name): KENNETH M ANDERSON R.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 KENNEDY ST NE
WASHINGTON DC
20011
US

IV. Provider business mailing address

823 KENNEDY ST NE
WASHINGTON DC
20011-2730
US

V. Phone/Fax

Practice location:
  • Phone: 860-447-0417
  • Fax: 860-447-2193
Mailing address:
  • Phone: 608-230-1528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number008333
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number25392
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: