Provider Demographics
NPI:1508906553
Name:MARY ANDERSON LCSW PC
Entity Type:Organization
Organization Name:MARY ANDERSON LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:719-475-0292
Mailing Address - Street 1:104 S CASCADE AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2250
Mailing Address - Country:US
Mailing Address - Phone:719-475-0292
Mailing Address - Fax:
Practice Address - Street 1:104 S CASCADE AVE
Practice Address - Street 2:SUITE203
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-2250
Practice Address - Country:US
Practice Address - Phone:719-475-0292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9892353189101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO537578Medicare ID - Type UnspecifiedCOUNSELOR MENTAL HEALTH