Provider Demographics
NPI:1770574501
Name:ANDERSON, CAROL ANNETTE (LCSW)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANNETTE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:C. ANNETTE
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3400 N CENTRAL EXPY
Mailing Address - Street 2:STE 110-270
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-0039
Mailing Address - Country:US
Mailing Address - Phone:972-814-0164
Mailing Address - Fax:
Practice Address - Street 1:3400 N CENTRAL EXPY
Practice Address - Street 2:STE 110-270
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-0039
Practice Address - Country:US
Practice Address - Phone:972-814-0164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-01
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9075101YP2500X
TX016311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0005089457OtherAETNA PIN
TX00S78JOtherBLUE CROSS BLUE SHIELD
TX009398OtherVALUE OPTIONS
TX1082711-02Medicaid
TX077171000OtherMAGELLAN
TX009398OtherVALUE OPTIONS