Healthcare Provider Details

I. General information

NPI: 1548892672
Provider Name (Legal Business Name): ANDERSON THERAPY GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W 4TH ST STE 103
ABERDEEN WA
98520-3932
US

IV. Provider business mailing address

PO BOX 558
COSMOPOLIS WA
98537-0558
US

V. Phone/Fax

Practice location:
  • Phone: 360-612-0456
  • Fax:
Mailing address:
  • Phone: 360-612-0411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. AMANDA N ANDERSON
Title or Position: OWNER
Credential: PHD
Phone: 360-500-1704