Healthcare Provider Details

I. General information

NPI: 1548421746
Provider Name (Legal Business Name): RUSTIE ADELL ANDERSON MSW, LCSW, CCSOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 MLK JR BLVD
EUGENE OR
97401-5824
US

IV. Provider business mailing address

2073 OLYMPIC ST
SPRINGFIELD OR
97477-3413
US

V. Phone/Fax

Practice location:
  • Phone: 541-682-3550
  • Fax: 541-682-9861
Mailing address:
  • Phone: 541-682-3550
  • Fax: 541-682-3551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5240
License Number StateOR

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: