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General NPI Number Information
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NPI Number | 1114585437
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Entity Type | Individual
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Provider Name | ANDREA ANDERSON
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Gender | Female
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Dates
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Enumeration Date | 06/01/2019
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Last Update Date | 06/01/2019
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Provider Practice Location Address
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Address Line | 5629 PROSPECT RD
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City | LONGMONT
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State | CO
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Zip | 80503-9047
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Country | US
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Telephone | 406-600-0879
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Fax |
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Provider Business Mailing Address
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Address Line | 5520 RACQUET LN
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City | BOULDER
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State | CO
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Zip | 80303-2941
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Country | US
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Telephone | 406-600-0879
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | NLC.0108060
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License Number State | CO
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