Provider Demographics
NPI:1649556739
Name:ANDERSON, CHARLES (MHPP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-2831
Mailing Address - Country:US
Mailing Address - Phone:501-955-2674
Mailing Address - Fax:501-955-2754
Practice Address - Street 1:1901 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-2831
Practice Address - Country:US
Practice Address - Phone:501-955-2674
Practice Address - Fax:501-955-2754
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator