Provider Demographics
NPI:1083706196
Name:ANDERSON, ORETA GAYLE (LCSW)
Entity Type:Individual
Prefix:
First Name:ORETA
Middle Name:GAYLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ORETA
Other - Middle Name:GAYLE
Other - Last Name:HINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10414
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-0414
Mailing Address - Country:US
Mailing Address - Phone:800-632-6074
Mailing Address - Fax:
Practice Address - Street 1:1105 S SUNSWEPT ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-4370
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000040901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3925799Medicaid
TN4051317OtherBCBS # - PARADIGM
TN3925799Medicaid