Provider Demographics
NPI:1205150208
Name:ANDERSON, GAYLE G (PLPC)
Entity type:Individual
Prefix:MR
First Name:GAYLE
Middle Name:G
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:MR
Other - First Name:ANDY
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PLPC
Mailing Address - Street 1:11 BAY OAKS CT
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-2127
Mailing Address - Country:US
Mailing Address - Phone:636-699-0872
Mailing Address - Fax:
Practice Address - Street 1:2850 W CLAY ST STE 255
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2579
Practice Address - Country:US
Practice Address - Phone:636-699-0872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010008296101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2010008296Medicaid