Provider Demographics
NPI:1992361521
Name:ANDERSON, THERESA MCCORMICK (LMLP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MCCORMICK
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 14TH RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:KS
Mailing Address - Zip Code:67579-8840
Mailing Address - Country:US
Mailing Address - Phone:620-278-6295
Mailing Address - Fax:
Practice Address - Street 1:217 EAST AVE N
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:KS
Practice Address - Zip Code:67554-1907
Practice Address - Country:US
Practice Address - Phone:620-257-5984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0612101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health