Provider Demographics
NPI:1811947856
Name:ANDERSON, JOHN PALMER (MAED)
Entity type:Individual
Prefix:PROF
First Name:JOHN
Middle Name:PALMER
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MAED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4105
Mailing Address - Country:US
Mailing Address - Phone:336-413-0143
Mailing Address - Fax:
Practice Address - Street 1:640 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2716
Practice Address - Country:US
Practice Address - Phone:336-725-3999
Practice Address - Fax:336-725-7720
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4296101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional