Provider Demographics
NPI:1639703689
Name:ANDERSON, RENITA T (LADAC)
Entity Type:Individual
Prefix:MRS
First Name:RENITA
Middle Name:T
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 E APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6925
Mailing Address - Country:US
Mailing Address - Phone:505-326-2012
Mailing Address - Fax:
Practice Address - Street 1:607 E APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6925
Practice Address - Country:US
Practice Address - Phone:505-326-2012
Practice Address - Fax:505-215-2814
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3900101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)