Healthcare Provider Details

I. General information

NPI: 1568499796
Provider Name (Legal Business Name): MARK WINSTON ANDEREGG LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 BUSH RIVER DRIVE
FARMVILLE VA
23901
US

IV. Provider business mailing address

13726 WAR ADMIRAL DR
MIDLOTHIAN VA
23112-6403
US

V. Phone/Fax

Practice location:
  • Phone: 434-392-3187
  • Fax: 434-392-5789
Mailing address:
  • Phone: 804-739-1130
  • Fax: 804-541-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904001959
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: