=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679816524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDERSON BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2013
-----------------------------------------------------
Last Update Date | 04/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13113 EASTPOINT PARK BLVD SUITE C
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40223-4191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-640-8550
-----------------------------------------------------
Fax | 502-489-5552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13113 EASTPOINT PARK BLVD SUITE C
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40223-4191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-640-8550
-----------------------------------------------------
Fax | 502-489-5552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAMES M ANDERSON
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 502-640-8550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 102
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1528
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------