=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740783513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDERSON COUNSELING AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2018
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 LITCHFIELD RD
-----------------------------------------------------
City | NEW MILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06776-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-731-1117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 198 PUMPKIN HILL RD
-----------------------------------------------------
City | NEW MILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06776-4654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-731-1117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KERRI ANDERSON
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 203-731-1117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 001563
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------