Healthcare Provider Details

I. General information

NPI: 1306027222
Provider Name (Legal Business Name): DIANE LEE ANDERSON RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 CHERRY ST
PHILADELPHIA PA
19106-1803
US

IV. Provider business mailing address

106 HILLCREST DR S
MACUNGIE PA
18062-1608
US

V. Phone/Fax

Practice location:
  • Phone: 800-974-6383
  • Fax:
Mailing address:
  • Phone: 610-730-4196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT000341E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: