MEDICARE: KERI JEAN ANDERSON CADC, CPGC, CPGC-S

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	0285	NV

General Provider Information

NPI Number	:	1962921130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERI JEAN ANDERSON CADC, CPGC, CPGC-S

Provider Business Mailing Address
First Line	:	635 AVENUE H
Second Line	:
City	:	BOULDER CITY
State	:	NV
Zip	:	89005-2725
Country	:	US
Telephone Number	:	702-499-2667
Fax Number	:

Provider Business Practice Location Address
First Line	:	3852 PALOS VERDES ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6909
Country	:	US
Telephone Number	:	702-485-1300
Fax Number	:	702-485-1210

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

Provider Enumeration Date	:	09/19/2017
Last Update Date	:	09/19/2017

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