Healthcare Provider Details

I. General information

NPI: 1568960797
Provider Name (Legal Business Name): CHARLIE ANDERSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39575 W 10 MILE RD STE 201
NOVI MI
48375
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 248-516-7250
  • Fax:
Mailing address:
  • Phone: 910-907-8922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number5501018524
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501018524
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: