Provider Demographics
NPI:1255423695
Name:ANDERSON, CONRAD ASHTON (LCSW, PHD)
Entity type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:ASHTON
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 BUDDELIA CV
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-4118
Mailing Address - Country:US
Mailing Address - Phone:228-365-3552
Mailing Address - Fax:228-392-9743
Practice Address - Street 1:1636 POPPS FERRY RD
Practice Address - Street 2:SUITE 215
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2217
Practice Address - Country:US
Practice Address - Phone:228-365-3552
Practice Address - Fax:228-392-9743
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2014-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSL.C.S.W. C#38221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I803223OtherMEDICARE PTAN
030389866OtherTRICARE
MS06656046OtherMS MEDICAID PROVIDER # 06656046