Healthcare Provider Details

I. General information

NPI: 1689693228
Provider Name (Legal Business Name): MARY BETH ANDERSON LCSW, CADCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JBLM 9040A JACKSON AVE
TACOMA WA
98431-1100
US

IV. Provider business mailing address

7012 ALDERWOOD CT SE
LACEY WA
98503-3422
US

V. Phone/Fax

Practice location:
  • Phone: 253-477-2285
  • Fax:
Mailing address:
  • Phone: 541-805-5765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL3394
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: