Provider Demographics
NPI:1780429902
Name:ANDERSON, LACRESIA T (PEER SUPPORT)
Entity type:Individual
Prefix:
First Name:LACRESIA
Middle Name:T
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PEER SUPPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2719 HOLLYGROVE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-1653
Mailing Address - Country:US
Mailing Address - Phone:504-408-6027
Mailing Address - Fax:
Practice Address - Street 1:3901 ULLOA ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6942
Practice Address - Country:US
Practice Address - Phone:504-267-5712
Practice Address - Fax:504-267-5714
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator