Provider Demographics
NPI:1164833596
Name:ANDERSON, PASSION (LMSW)
Entity Type:Individual
Prefix:
First Name:PASSION
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 S UNION ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-1834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 EAST AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-2638
Practice Address - Country:US
Practice Address - Phone:585-325-5100
Practice Address - Fax:585-325-5154
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0905301101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1073614533Medicaid