Provider Demographics
NPI:1174910343
Name:ANDERSON, ANGELA BETH (PTA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:BETH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 GLENVIEW DR
Mailing Address - Street 2:#106
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-3744
Mailing Address - Country:US
Mailing Address - Phone:408-679-0216
Mailing Address - Fax:
Practice Address - Street 1:752 GLENVIEW DR
Practice Address - Street 2:APT 106
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3744
Practice Address - Country:US
Practice Address - Phone:408-679-0216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT8122225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant