Provider Demographics
NPI:1659637346
Name:ANDERSON, TERESA LYNNE
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNNE
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 1:2180 MARAVILLA LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7221
Mailing Address - Country:US
Mailing Address - Phone:352-601-8118
Mailing Address - Fax:239-332-4977
Practice Address - Street 1:2180 MARAVILLA LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7221
Practice Address - Country:US
Practice Address - Phone:352-601-8118
Practice Address - Fax:239-332-4977
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor