Provider Demographics
NPI:1174860290
Name:ANDERSON, LEELLEN LOU (LASAC)
Entity Type:Individual
Prefix:
First Name:LEELLEN
Middle Name:LOU
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 N IRVING ST
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3117
Mailing Address - Country:US
Mailing Address - Phone:928-718-4800
Mailing Address - Fax:928-718-5666
Practice Address - Street 1:2002 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4698
Practice Address - Country:US
Practice Address - Phone:928-718-4800
Practice Address - Fax:928-718-5666
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLASAC 13268101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)