Provider Demographics
NPI:1053733188
Name:ANDERSON, AMY SOUTHERLAND (PT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SOUTHERLAND
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4432 GOLDFINCH WAY
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-8716
Mailing Address - Country:US
Mailing Address - Phone:850-603-0317
Mailing Address - Fax:
Practice Address - Street 1:4432 GOLDFINCH WAY
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-8716
Practice Address - Country:US
Practice Address - Phone:850-603-0317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist