Healthcare Provider Details

I. General information

NPI: 1396141644
Provider Name (Legal Business Name): GREGORY ANDERSEN SR. BA LCDP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 COLUMBIA ST
WAKEFIELD RI
02879-2494
US

IV. Provider business mailing address

30 LAKESIDE DR
CHARLESTOWN RI
02813-3143
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-0934
  • Fax:
Mailing address:
  • Phone: 401-789-0934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP00478
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: