Provider Demographics
NPI:1629610373
Name:ANDERSON, ELIZABETH ANN
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 N 16TH ST STE 122
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1265
Mailing Address - Country:US
Mailing Address - Phone:602-636-4486
Mailing Address - Fax:
Practice Address - Street 1:2701 N 16TH ST STE 122
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-1265
Practice Address - Country:US
Practice Address - Phone:602-636-4486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLASAC-13210101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)