Provider Demographics
NPI:1528580313
Name:ANDERSON, GARLAND (MS)
Entity Type:Individual
Prefix:MR
First Name:GARLAND
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3644 SW MASILUNAS ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5247
Mailing Address - Country:US
Mailing Address - Phone:772-252-9318
Mailing Address - Fax:
Practice Address - Street 1:2100 SE HILLMOOR DR STE 205
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-8057
Practice Address - Country:US
Practice Address - Phone:772-252-9318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH15887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health