Provider Demographics
NPI:1043037732
Name:ANDERSON, ELLEN KATHERYNE (OTA-L APPLICANT)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:KATHERYNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTA-L APPLICANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7164 MARECAGE CT
Mailing Address - Street 2:
Mailing Address - City:NEW KENT
Mailing Address - State:VA
Mailing Address - Zip Code:23124-3121
Mailing Address - Country:US
Mailing Address - Phone:804-944-6102
Mailing Address - Fax:
Practice Address - Street 1:1600 WESTWOOD AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-4622
Practice Address - Country:US
Practice Address - Phone:804-552-6418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPENDING224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant