Provider Demographics
NPI:1780707562
Name:ANDERSON, CHARLES S JR (MA, LMHC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 SUMMER ST
Mailing Address - Street 2:SUITE 025
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-5783
Mailing Address - Country:US
Mailing Address - Phone:978-345-0685
Mailing Address - Fax:978-342-8495
Practice Address - Street 1:76 SUMMER ST
Practice Address - Street 2:SUITE 025
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-5783
Practice Address - Country:US
Practice Address - Phone:978-345-6729
Practice Address - Fax:978-342-7503
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5064OtherALLIED MENTAL HEALTH