Healthcare Provider Details

I. General information

NPI: 1053518977
Provider Name (Legal Business Name): MONTAQUE ANN ANDERSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 COUNTRY CLUB DR
HUNTINGTON WV
25705-2000
US

IV. Provider business mailing address

1808 ROUNDHILL RD
CHARLESTON WV
25314-1538
US

V. Phone/Fax

Practice location:
  • Phone: 304-733-1060
  • Fax: 304-733-9284
Mailing address:
  • Phone: 304-419-4189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number000209
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: