Provider Demographics
NPI:1194815753
Name:ANDERSON, MARY S (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:S
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S CASCADE AVE
Mailing Address - Street 2:STE 111
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-5101
Mailing Address - Country:US
Mailing Address - Phone:719-475-0292
Mailing Address - Fax:
Practice Address - Street 1:104 S CASCADE AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-2250
Practice Address - Country:US
Practice Address - Phone:719-475-0292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9892353189101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO537578Medicare ID - Type UnspecifiedINDIVIDUAL ID#