MEDICARE: MRS. STELLA LYNN ANDERSON LCSW

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	1041C0700X	Clinical Social Worker	36574	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	36574	OTHER	TX	LCSW (SOCIAL WORK LICENSE

General Provider Information

NPI Number	:	1710189576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STELLA LYNN ANDERSON LCSW

Provider Business Mailing Address
First Line	:	413 PALMETTO POINT RD
Second Line	:	HOLIDAY BEACH ADDITION
City	:	ROCKPORT
State	:	TX
Zip	:	78382-9363
Country	:	US
Telephone Number	:	361-727-7301
Fax Number	:

Provider Business Practice Location Address
First Line	:	413 PALMETTO POINT RD
Second Line	:	HOLIDAY BEACH ADDITION
City	:	ROCKPORT
State	:	TX
Zip	:	78382-9363
Country	:	US
Telephone Number	:	361-727-7301
Fax Number	:

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

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	07/08/2007

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