Provider Demographics
NPI:1467899625
Name:ANDERSON, MALISSIA WILLOWDAWN (MHT)
Entity Type:Individual
Prefix:
First Name:MALISSIA
Middle Name:WILLOWDAWN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 LATHROP ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7426
Mailing Address - Country:US
Mailing Address - Phone:907-459-4700
Mailing Address - Fax:
Practice Address - Street 1:3101 LATHROP STREET
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-459-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH3237Medicaid