Provider Demographics
NPI:1841710282
Name:ANDERSON, MINDI ANN (CAADE CATC III)
Entity type:Individual
Prefix:
First Name:MINDI
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CAADE CATC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 N SACRAMENTO ST STE H
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-1251
Mailing Address - Country:US
Mailing Address - Phone:209-376-5433
Mailing Address - Fax:
Practice Address - Street 1:856 N SACRAMENTO ST STE H
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-1251
Practice Address - Country:US
Practice Address - Phone:209-367-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123120101Y00000X, 101YP2500X, 101YA0400X
374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner