Provider Demographics
NPI:1497807416
Name:ANDERSON, KATIE MARIE (LPC M COUN)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPC M COUN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 E 10 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442
Mailing Address - Country:US
Mailing Address - Phone:208-351-5539
Mailing Address - Fax:
Practice Address - Street 1:1740 E 17TH ST STEB
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-351-5539
Practice Address - Fax:208-522-8725
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC3597101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010155545OtherBLUE SHIELD OF IDAHO
IDX6890OtherBLUE CROSS OF IDAHO