Provider Demographics
NPI:1679078349
Name:PIERCE, ANISA NOEL
Entity Type:Individual
Prefix:
First Name:ANISA
Middle Name:NOEL
Last Name:PIERCE
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 1:1822 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-2327
Mailing Address - Country:US
Mailing Address - Phone:916-899-2705
Mailing Address - Fax:
Practice Address - Street 1:1358 BLUE OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-7040
Practice Address - Country:US
Practice Address - Phone:916-676-0488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CARBT-17-0316-57058106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty