Healthcare Provider Details

I. General information

NPI: 1669193918
Provider Name (Legal Business Name): MELISSA ANDERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13471 W CORNERSTONE BLVD
GOODYEAR AZ
85395-2713
US

IV. Provider business mailing address

3033 N CENTRAL AVE STE 145
PHOENIX AZ
85012-2808
US

V. Phone/Fax

Practice location:
  • Phone: 480-964-2273
  • Fax: 623-213-8808
Mailing address:
  • Phone: 623-583-3001
  • Fax: 623-974-6721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-17026
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-22405
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: