Healthcare Provider Details

I. General information

NPI: 1700473469
Provider Name (Legal Business Name): SHELBY LEA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 SAM NEWELL RD STE 103
MATTHEWS NC
28105-5016
US

IV. Provider business mailing address

2041 BERKLEY HALL WAY APT 201
FORT MILL SC
29708-0036
US

V. Phone/Fax

Practice location:
  • Phone: 980-202-2288
  • Fax:
Mailing address:
  • Phone: 907-982-7704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP014824
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP014824
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: