Provider Demographics
NPI:1972280501
Name:ANDERSON, MARTHA KEENAN (LPC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:KEENAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:J
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1503 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2259
Mailing Address - Country:US
Mailing Address - Phone:708-657-8876
Mailing Address - Fax:
Practice Address - Street 1:310 W PLAZA DR
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1980
Practice Address - Country:US
Practice Address - Phone:618-985-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018609101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional