Provider Demographics
NPI:1881736304
Name:ANDERSON, CARLA SUE (MA, LPC)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:SUE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 QUAIL RUN
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-3180
Mailing Address - Country:US
Mailing Address - Phone:404-570-3764
Mailing Address - Fax:
Practice Address - Street 1:1778 CENTURY BLVD NE
Practice Address - Street 2:SUITE A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3398
Practice Address - Country:US
Practice Address - Phone:404-570-3764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002385101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52546104001Medicare UPIN
GA0007045865Medicare UPIN