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General NPI Number Information
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NPI Number | 1487474714
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Entity Type | Individual
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Provider Name | DESERAE ANDERSON
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Gender | Female
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Dates
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Enumeration Date | 10/11/2024
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Last Update Date | 10/11/2024
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Provider Practice Location Address
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Address Line | 1210 TECH BLVD
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City | TAMPA
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State | FL
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Zip | 33619
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Country | US
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Telephone | 727-589-8053
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Fax |
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Provider Business Mailing Address
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Address Line | 6795 16TH ST S
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City | ST PETERSBURG
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State | FL
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Zip | 33705-6026
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Country | US
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Telephone |
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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 | IMH23757
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License Number State | FL
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