Provider Demographics
NPI:1396455358
Name:ANDERSON, IRENE (LGPC)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11810 GRAND PARK AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:NORTH BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-8679
Mailing Address - Country:US
Mailing Address - Phone:301-633-8516
Mailing Address - Fax:
Practice Address - Street 1:11810 GRAND PARK AVE STE 500
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-8679
Practice Address - Country:US
Practice Address - Phone:301-633-8516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP13368101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLGP13368OtherPRIVATE PAY