Provider Demographics
NPI:1124202965
Name:ANDERSON, DALE R (MA, LPC)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-3170
Mailing Address - Country:US
Mailing Address - Phone:269-344-0202
Mailing Address - Fax:269-344-0285
Practice Address - Street 1:450 MEADOW RUN DR
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-9053
Practice Address - Country:US
Practice Address - Phone:269-344-0202
Practice Address - Fax:269-344-0285
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006507101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional