Provider Demographics
NPI:1619303385
Name:ANDERSON, ELIZABETH L (PSYD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 HAMILTON MILL RD STE 102-142
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4080
Mailing Address - Country:US
Mailing Address - Phone:770-674-8257
Mailing Address - Fax:855-788-4782
Practice Address - Street 1:1755 N BROWN RD STE 200
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043
Practice Address - Country:US
Practice Address - Phone:770-674-8257
Practice Address - Fax:855-788-4782
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3906103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000WDBCHOtherMEDICARE
OR164936Medicaid