Provider Demographics
NPI:1376946111
Name:ANDERSON, CAROLYN ILENE (MA)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:ILENE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1447
Mailing Address - Country:US
Mailing Address - Phone:253-209-4578
Mailing Address - Fax:
Practice Address - Street 1:4301 S PINE ST
Practice Address - Street 2:SUITE #501
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7264
Practice Address - Country:US
Practice Address - Phone:253-209-4578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH0011245101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health