Provider Demographics
NPI:1134880313
Name:ANDERSON, GARY LEE JR (AAS, PLADC)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEE
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:AAS, PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 JOHN GALT BLVD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2319
Mailing Address - Country:US
Mailing Address - Phone:402-592-5900
Mailing Address - Fax:402-592-5901
Practice Address - Street 1:11215 JOHN GALT BLVD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2319
Practice Address - Country:US
Practice Address - Phone:402-592-5900
Practice Address - Fax:402-592-5901
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP1502101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1073874731Medicaid