Provider Demographics
NPI:1003255340
Name:ANDERSON, ELIZABETH (PCA)
Entity Type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 KIM DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23224-5643
Mailing Address - Country:US
Mailing Address - Phone:502-435-8295
Mailing Address - Fax:
Practice Address - Street 1:5010 UNSELD BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3836
Practice Address - Country:US
Practice Address - Phone:502-479-5699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAE026044101YM0800X
VAA63489901347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE026044Medicaid