Provider Demographics
NPI:1912253501
Name:ANDERSON, NANCY MAE (LPC)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:MAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 N WASHINGTON ST
Mailing Address - Street 2:5E
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8289
Mailing Address - Country:US
Mailing Address - Phone:719-330-6614
Mailing Address - Fax:719-623-0488
Practice Address - Street 1:236 N WASHINGTON ST
Practice Address - Street 2:5E
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-8289
Practice Address - Country:US
Practice Address - Phone:719-330-6614
Practice Address - Fax:719-623-0488
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2016-09-16
Deactivation Date:2015-03-11
Deactivation Code:
Reactivation Date:2015-12-18
Provider Licenses
StateLicense IDTaxonomies
CO6290101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34671749Medicaid