=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780263426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN T ANDERSON LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2021
-----------------------------------------------------
Last Update Date | 04/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 729 PECAN GROVE LN
-----------------------------------------------------
City | JEFFERSON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70121-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-470-3303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 729 PECAN GROVE LN
-----------------------------------------------------
City | JEFFERSON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70121-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-470-3303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 14092
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------