Provider Demographics
NPI:1013187632
Name:ANDERSON, MARK R
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WOODWIND DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-4517
Mailing Address - Country:US
Mailing Address - Phone:864-707-1953
Mailing Address - Fax:
Practice Address - Street 1:324 E SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1505
Practice Address - Country:US
Practice Address - Phone:864-707-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
SC5246101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC421504Medicaid