Healthcare Provider Details

I. General information

NPI: 1538364740
Provider Name (Legal Business Name): TERRY ANDERSON MA, MSW, DMIN, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W WAYNE ST
FORT WAYNE IN
46802-3608
US

IV. Provider business mailing address

300 W WAYNE ST
FORT WAYNE IN
46802-3608
US

V. Phone/Fax

Practice location:
  • Phone: 260-422-8556
  • Fax: 260-422-8558
Mailing address:
  • Phone: 260-422-8556
  • Fax: 260-422-8558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003367A
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: