Provider Demographics
NPI:1174660724
Name:ANDERSON, DONELLE (MFT)
Entity Type:Individual
Prefix:
First Name:DONELLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3334 CESSNA DR
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-9133
Mailing Address - Country:US
Mailing Address - Phone:530-647-6907
Mailing Address - Fax:530-350-8775
Practice Address - Street 1:4944 WINDPLAY DR STE 114
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9310
Practice Address - Country:US
Practice Address - Phone:530-647-6907
Practice Address - Fax:530-350-8775
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT49287106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174660724OtherAGAENCY