Provider Demographics
NPI:1699844407
Name:ANDERSON, JOHN KIRK (LPCC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KIRK
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 N TURNER
Mailing Address - Street 2:SUITE 101A
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-4309
Mailing Address - Country:US
Mailing Address - Phone:575-390-2529
Mailing Address - Fax:
Practice Address - Street 1:920 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-5529
Practice Address - Country:US
Practice Address - Phone:505-393-3168
Practice Address - Fax:505-397-4659
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1192101YP2500X
TX13788101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46300Medicaid