Healthcare Provider Details

I. General information

NPI: 1376115287
Provider Name (Legal Business Name): WILLIE ANDERSON JR. AACT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 AIME ST
DENHAM SPRINGS LA
70726-4102
US

IV. Provider business mailing address

1040 AIME ST
DENHAM SPRINGS LA
70726-4102
US

V. Phone/Fax

Practice location:
  • Phone: 225-747-1563
  • Fax:
Mailing address:
  • Phone: 225-747-1563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberWA861035
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberWA861035
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberWA861035
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberWA861035
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: