Healthcare Provider Details

I. General information

NPI: 1063195592
Provider Name (Legal Business Name): MARK D ANDERSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 05/17/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 CHERITON CT
CUMMING GA
30041-7951
US

IV. Provider business mailing address

2430 CHERITON CT
CUMMING GA
30041-7951
US

V. Phone/Fax

Practice location:
  • Phone: 908-962-7532
  • Fax:
Mailing address:
  • Phone: 908-962-5753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMARKDA714
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: