Provider Demographics
NPI:1093455396
Name:ANDERSON, PATRICK (LISAC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 N 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-4607
Mailing Address - Country:US
Mailing Address - Phone:623-322-6143
Mailing Address - Fax:480-781-4566
Practice Address - Street 1:3930 N 30TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4607
Practice Address - Country:US
Practice Address - Phone:623-322-6143
Practice Address - Fax:480-781-4566
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15174101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ091903Medicaid