Provider Demographics
NPI:1023436771
Name:ANDERSON, RAEQUAEL (MS, LPC, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:RAEQUAEL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS, LPC, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3661 N PLANO RD STE 3500
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2029
Mailing Address - Country:US
Mailing Address - Phone:469-488-7300
Mailing Address - Fax:214-867-5490
Practice Address - Street 1:3661 N PLANO RD # 3500
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2029
Practice Address - Country:US
Practice Address - Phone:469-488-7300
Practice Address - Fax:214-867-5490
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-13-14458103K00000X
TX74407101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty