Provider Demographics
NPI:1255567780
Name:ANDERSON, JUSTIN SHAW (LCSW)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:SHAW
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 PLUM ST STE F
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-7583
Mailing Address - Country:US
Mailing Address - Phone:229-241-8995
Mailing Address - Fax:229-241-8997
Practice Address - Street 1:1810 PLUM ST STE F
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-7583
Practice Address - Country:US
Practice Address - Phone:229-241-8995
Practice Address - Fax:229-241-8997
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0039461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3012275978AMedicaid