Provider Demographics
NPI:1023279080
Name:ANDERSON, KENNETH M (RPT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 KENNEDY ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-2730
Mailing Address - Country:US
Mailing Address - Phone:608-230-1528
Mailing Address - Fax:
Practice Address - Street 1:823 KENNEDY ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011
Practice Address - Country:US
Practice Address - Phone:860-447-0417
Practice Address - Fax:860-447-2193
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0083332251X0800X
MD25392225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic