Provider Demographics
NPI:1376115287
Name:ANDERSON, WILLIE JR (AACT)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:AACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 AIME ST
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-4102
Mailing Address - Country:US
Mailing Address - Phone:225-747-1563
Mailing Address - Fax:
Practice Address - Street 1:1040 AIME ST
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-4102
Practice Address - Country:US
Practice Address - Phone:225-747-1563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAWA861035101YM0800X, 101YP1600X, 101YA0400X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty