Provider Demographics
NPI:1558673848
Name:ANDERSON, SUSAN L (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 FAIRVIEW AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2056
Mailing Address - Country:US
Mailing Address - Phone:580-762-2222
Mailing Address - Fax:580-762-2229
Practice Address - Street 1:300 FAIRVIEW AVE STE 2
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2056
Practice Address - Country:US
Practice Address - Phone:580-762-2222
Practice Address - Fax:580-762-2229
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-02
Last Update Date:2011-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2895101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional