Provider Demographics
NPI:1649775248
Name:ANDERSON, KARISSA L (LPCC, NCC)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPCC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 802
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-0802
Mailing Address - Country:US
Mailing Address - Phone:859-985-7862
Mailing Address - Fax:859-972-0616
Practice Address - Street 1:292 GLADES RD STE 8
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1368
Practice Address - Country:US
Practice Address - Phone:859-859-7862
Practice Address - Fax:859-972-0616
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY262999101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100656970Medicaid