Provider Demographics
NPI:1154492528
Name:ANDERSON, IRENE (MED)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 N CAMPBELL AVE
Mailing Address - Street 2:P.O. BOX 379
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-3304
Mailing Address - Country:US
Mailing Address - Phone:520-624-3717
Mailing Address - Fax:520-795-6998
Practice Address - Street 1:2230 E SPEEDWAY BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-4761
Practice Address - Country:US
Practice Address - Phone:520-624-3717
Practice Address - Fax:520-795-6998
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-0280101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health