Provider Demographics
NPI:1356363600
Name:ANDERSON, MARY ELLEN (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 BERLIN PLANK RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-2069
Mailing Address - Country:US
Mailing Address - Phone:814-701-2898
Mailing Address - Fax:814-701-2917
Practice Address - Street 1:485 BERLIN PLANK RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-2069
Practice Address - Country:US
Practice Address - Phone:814-701-2898
Practice Address - Fax:814-701-2917
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1041C0700X
PACW0130621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000001750051Medicaid
PA1029029280002Medicaid
PA1000001750051Medicaid
PA1029029280002Medicaid