Provider Demographics
NPI:1629716535
Name:UNDERWOOD, ANISSA B
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:B
Last Name:UNDERWOOD
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 1:339 RACE ST APT A1
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-1226
Mailing Address - Country:US
Mailing Address - Phone:570-422-6522
Mailing Address - Fax:
Practice Address - Street 1:5221 MILFORD RD
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18302-9149
Practice Address - Country:US
Practice Address - Phone:570-422-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)