Provider Demographics
NPI:1801108535
Name:ANDERSON, JOHN C (LCSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83-35 139TH STREET
Mailing Address - Street 2:UNIT 2D
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435
Mailing Address - Country:US
Mailing Address - Phone:718-575-0926
Mailing Address - Fax:212-979-1359
Practice Address - Street 1:83-35 139TH STREET
Practice Address - Street 2:UNIT 2D
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435
Practice Address - Country:US
Practice Address - Phone:718-575-0926
Practice Address - Fax:212-979-1359
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-10
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR023968-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical