Healthcare Provider Details

I. General information

NPI: 1760173264
Provider Name (Legal Business Name): AUDREY ANDERSON LAC LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 MILLER STREET 2ND FLOOR
NEWARK NJ
07114-1750
US

IV. Provider business mailing address

590 NORTH 7TH STREET
NEWARK NJ
07107
US

V. Phone/Fax

Practice location:
  • Phone: 973-596-4190
  • Fax: 973-639-6583
Mailing address:
  • Phone: 800-227-7705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number37AC00551600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00334900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: