Provider Demographics
NPI:1114244019
Name:ANDERSON, JUSTIN ERIC
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ERIC
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 1:142 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-5008
Mailing Address - Country:US
Mailing Address - Phone:580-920-2069
Mailing Address - Fax:580-920-1010
Practice Address - Street 1:142 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-5008
Practice Address - Country:US
Practice Address - Phone:580-920-2069
Practice Address - Fax:580-920-1010
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-01
Last Update Date:2010-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor