Provider Demographics
NPI:1417095795
Name:ANDERSON, THERESA C (LCPC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2814
Mailing Address - Country:US
Mailing Address - Phone:207-482-3850
Mailing Address - Fax:
Practice Address - Street 1:37 MELODY LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2814
Practice Address - Country:US
Practice Address - Phone:617-947-5889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3177101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432426099Medicaid