Healthcare Provider Details

I. General information

NPI: 1124687215
Provider Name (Legal Business Name): ELIZABETH ANDERSON R-DMT, RYT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 PATTERSON RD
HANSCOM AFB MA
01731-2651
US

IV. Provider business mailing address

116 PATTERSON RD
HANSCOM AFB MA
01731-2651
US

V. Phone/Fax

Practice location:
  • Phone: 850-420-2399
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number1564
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: