MEDICARE: MCKENNA LISE ANDERSON MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT 37625	CA

General Provider Information

NPI Number	:	1942508387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENNA LISE ANDERSON MPT

Provider Business Mailing Address
First Line	:	4908 VALLEY RIDGE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-1029
Country	:	US
Telephone Number	:	323-294-7671
Fax Number	:

Provider Business Practice Location Address
First Line	:	6133 BRISTOL PKWY
Second Line	:	SUITE 200
City	:	CULVER CITY
State	:	CA
Zip	:	90230-6609
Country	:	US
Telephone Number	:	310-337-7600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2011
Last Update Date	:	03/09/2011

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