Provider Demographics
NPI:1457842072
Name:ANDERSEN, CORRINE M
Entity Type:Individual
Prefix:
First Name:CORRINE
Middle Name:M
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3641 ENGLISH GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-8083
Mailing Address - Country:US
Mailing Address - Phone:704-807-2488
Mailing Address - Fax:
Practice Address - Street 1:603 COX RD STE C
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3432
Practice Address - Country:US
Practice Address - Phone:704-807-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13957101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health