=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255423695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONRAD ASHTON ANDERSON L.C.S.W., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 02/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1636 POPPS FERRY RD SUITE 215
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39532-2217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-365-3552
-----------------------------------------------------
Fax | 228-392-9743
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 739 BUDDELIA CV
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39532-4118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-365-3552
-----------------------------------------------------
Fax | 228-392-9743
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | L.C.S.W. C#3822
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------