Healthcare Provider Details

I. General information

NPI: 1861835282
Provider Name (Legal Business Name): ASHLEY B ANDERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASHLEY BRADDY ANDERSON LCSW

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 GRANTS FERRY RD
BRANDON MS
39047-9023
US

IV. Provider business mailing address

609 OAKVIEW WAY
BYRAM MS
39272-8754
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4162
  • Fax:
Mailing address:
  • Phone: 601-941-6453
  • Fax: 601-878-9083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberM7921
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC7921
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: