MEDICARE: CHARLES C. ANDERSON ED.D REG PSY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	071.002741	IL

General Provider Information

NPI Number	:	1194963082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES C. ANDERSON ED.D REG PSY

Provider Business Mailing Address
First Line	:	3411 N KENNICOTT AVE
Second Line	:	B
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-7813
Country	:	US
Telephone Number	:	847-398-1717
Fax Number	:	773-348-5271

Provider Business Practice Location Address
First Line	:	2030 N MAGNOLIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4010
Country	:	US
Telephone Number	:	847-398-1717
Fax Number	:	773-348-5271

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES C. ANDERSON
Credential	:	ED.D
Telephone Number	:	847-398-1717

Provider Enumeration Date	:	01/30/2009
Last Update Date	:	01/30/2009

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