Provider Demographics
NPI:1760173264
Name:ANDERSON, AUDREY (LAC LCADC)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LAC LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 NORTH 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107
Mailing Address - Country:US
Mailing Address - Phone:800-227-7705
Mailing Address - Fax:
Practice Address - Street 1:47 MILLER STREET 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07114-1750
Practice Address - Country:US
Practice Address - Phone:973-596-4190
Practice Address - Fax:973-639-6583
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00551600101Y00000X
NJ37LC00334900101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor