Provider Demographics
NPI:1962643650
Name:ANDERSON, ADDIE W (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:ADDIE
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 S TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1621
Mailing Address - Country:US
Mailing Address - Phone:708-870-6255
Mailing Address - Fax:708-524-8492
Practice Address - Street 1:7326 HARRISON ST
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2017
Practice Address - Country:US
Practice Address - Phone:708-870-6255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005782101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional