Provider Demographics
NPI:1063966554
Name:ANDERSON, ETHAN (DPT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:15410 S MOUNTAIN PKWY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-706-1161
Mailing Address - Fax:480-706-7997
Practice Address - Street 1:7707 W DEER VALLEY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2101
Practice Address - Country:US
Practice Address - Phone:623-376-9100
Practice Address - Fax:623-376-9141
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ12383225100000X
2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic