Healthcare Provider Details

I. General information

NPI: 1174738439
Provider Name (Legal Business Name): PEARL A. ANDERSON ACIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 W WESTERN AVE
SOUTH BEND IN
46619-2617
US

IV. Provider business mailing address

4005 W WESTERN AVE
SOUTH BEND IN
46619-2617
US

V. Phone/Fax

Practice location:
  • Phone: 574-233-1524
  • Fax: 574-233-1612
Mailing address:
  • Phone: 574-233-1524
  • Fax: 574-233-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: