Provider Demographics
NPI:1376250506
Name:ANDERSON, QUENTON CARDELL
Entity Type:Individual
Prefix:
First Name:QUENTON
Middle Name:CARDELL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 WEST 95TH
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453
Mailing Address - Country:US
Mailing Address - Phone:708-529-0278
Mailing Address - Fax:
Practice Address - Street 1:569 WEST 95TH STREET
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-6045
Practice Address - Country:US
Practice Address - Phone:708-529-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.108327104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker