Provider Demographics
NPI:1952722480
Name:ANDERSEN, REBECCA (LAC)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17505 N. 79TH AVE
Mailing Address - Street 2:SUITE 111C
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308
Mailing Address - Country:US
Mailing Address - Phone:623-680-8054
Mailing Address - Fax:
Practice Address - Street 1:17505 N. 79TH AVE
Practice Address - Street 2:SUITE 111C
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:623-680-8054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-13812101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor