Healthcare Provider Details

I. General information

NPI: 1861903924
Provider Name (Legal Business Name): DEBRA L ANDERSEN RYT-200
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date: 02/25/2020
Reactivation Date: 05/12/2026

III. Provider practice location address

17390 S INDIGO CREST PASS
VAIL AZ
85641-2769
US

IV. Provider business mailing address

17390 S INDIGO CREST PASS
VAIL AZ
85641-2769
US

V. Phone/Fax

Practice location:
  • Phone: 760-553-3558
  • Fax:
Mailing address:
  • Phone: 760-553-3558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-LA-897
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-24364
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-3481609
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-OH-899
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-MN-898
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCP6331-R
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: