Healthcare Provider Details

I. General information

NPI: 1598843591
Provider Name (Legal Business Name): DONALD ANDERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 ELECTRIC RD STE 156
ROANOKE VA
24018-4571
US

IV. Provider business mailing address

3959 ELECTRIC RD STE 156
ROANOKE VA
24018-4571
US

V. Phone/Fax

Practice location:
  • Phone: 540-772-3119
  • Fax: 540-387-1047
Mailing address:
  • Phone: 540-772-3119
  • Fax: 540-387-1047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0717000655
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701000664
License Number StateVA

VIII. Authorized Official

Name: DR. DONALD ANDERSON
Title or Position: OWNER
Credential: LPC
Phone: 540-797-0569