Provider Demographics
NPI:1770645285
Name:ANDERSON, MARVIN NEIL (LCSW)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:NEIL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CHESTERLY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-7339
Mailing Address - Country:US
Mailing Address - Phone:509-712-2902
Mailing Address - Fax:509-554-5595
Practice Address - Street 1:1200 CHESTERLY DR STE 100
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-7339
Practice Address - Country:US
Practice Address - Phone:509-712-2902
Practice Address - Fax:509-554-5595
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW605394011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3925891Medicaid
TN4110408OtherBLUECROSS BLUESHIELD #
TN500566OtherVALUE OPTIONS PROVIDER #
TN3925891Medicare ID - Type UnspecifiedMEDICARE NUMBER