Provider Demographics
NPI:1801249321
Name:ANDERSON, AMY (LPCA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 SECOND BAXTER XING
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-6401
Mailing Address - Country:US
Mailing Address - Phone:704-904-2494
Mailing Address - Fax:
Practice Address - Street 1:1870 SECOND BAXTER XING
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6401
Practice Address - Country:US
Practice Address - Phone:704-904-2494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12155101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional