Provider Demographics
NPI:1679826168
Name:ANDERSON, JANELLE MARIE (LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2405
Mailing Address - Country:US
Mailing Address - Phone:262-638-6744
Mailing Address - Fax:262-638-6540
Practice Address - Street 1:1717 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2405
Practice Address - Country:US
Practice Address - Phone:262-638-6744
Practice Address - Fax:262-638-6540
Is Sole Proprietor?:No
Enumeration Date:2012-10-21
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16289-132101YA0400X
WI8838-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)