Provider Demographics
NPI:1790095743
Name:ANICCA LLC
Entity Type:Organization
Organization Name:ANICCA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-421-5904
Mailing Address - Street 1:1020 SW TAYLOR ST STE 685
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2511
Mailing Address - Country:US
Mailing Address - Phone:503-421-5904
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST STE 685
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2511
Practice Address - Country:US
Practice Address - Phone:503-421-5904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty