Provider Demographics
NPI:1164620662
Name:ANDERSON, JOHN LEE (CSAC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CATHY DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-1403
Mailing Address - Country:US
Mailing Address - Phone:757-344-0459
Mailing Address - Fax:
Practice Address - Street 1:2238 TODDS LN
Practice Address - Street 2:SUITE D
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3159
Practice Address - Country:US
Practice Address - Phone:757-262-2094
Practice Address - Fax:757-262-2095
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102044101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)