MEDICARE: TENNILLE ANDERSON MENTAL HEALTH STUDEN

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1427450758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TENNILLE ANDERSON MENTAL HEALTH STUDEN

Provider Business Mailing Address
First Line	:	249 THOMAS S BOYLAND ST APT 7F
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11233-4127
Country	:	US
Telephone Number	:	917-554-9904
Fax Number	:

Provider Business Practice Location Address
First Line	:	249 THOMAS S BOYLAND ST APT 7F
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11233-4127
Country	:	US
Telephone Number	:	917-554-9904
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2014
Last Update Date	:	09/18/2014

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