Healthcare Provider Details

I. General information

NPI: 1568398097
Provider Name (Legal Business Name): HEIDI ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 N MAIN ST STE 100B
NORTH SYRACUSE NY
13212-1661
US

IV. Provider business mailing address

214 GRENADIER DR APT F
LIVERPOOL NY
13090-2752
US

V. Phone/Fax

Practice location:
  • Phone: 315-216-1465
  • Fax:
Mailing address:
  • Phone: 850-797-7429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberP143606
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: