MEDICARE: CONNIE L ANDERSON LPC

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	101YP2500X	Professional Counselor	2346	MS

General Provider Information

NPI Number	:	1962976613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE L ANDERSON LPC

Provider Business Mailing Address
First Line	:	105 ASBURY CIR STE A
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1397
Country	:	US
Telephone Number	:	601-264-7079
Fax Number	:	601-296-7819

Provider Business Practice Location Address
First Line	:	105 ASBURY CIR STE A
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1397
Country	:	US
Telephone Number	:	601-264-7079
Fax Number	:	601-296-7819

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

Provider Enumeration Date	:	01/16/2019
Last Update Date	:	01/16/2019

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Directions to “ CONNIE L ANDERSON LPC” Practice Location

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