Provider Demographics
NPI:1679399240
Name:ANDERSON, CHARNEL (PTA)
Entity type:Individual
Prefix:
First Name:CHARNEL
Middle Name:
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 1:23007 MCCOOL DR
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-2433
Mailing Address - Country:US
Mailing Address - Phone:850-512-0733
Mailing Address - Fax:
Practice Address - Street 1:29770 THREE NOTCH RD STE 201
Practice Address - Street 2:
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622-3192
Practice Address - Country:US
Practice Address - Phone:301-290-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-28
Last Update Date:2024-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA6029225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant