Provider Demographics
NPI:1275544173
Name:ANDERSON, ROGER (LCSW, LCDC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12810 BORIS COVE TRL
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77047-4024
Mailing Address - Country:US
Mailing Address - Phone:713-857-8795
Mailing Address - Fax:
Practice Address - Street 1:2002 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4211
Practice Address - Country:US
Practice Address - Phone:713-791-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039952901Medicaid
TX82056WMedicare ID - Type Unspecified
TX039952901Medicaid