Provider Demographics
NPI:1952767543
Name:ANDERSON, VANESSA H (LPC)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:H
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 1:543 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-3752
Mailing Address - Country:US
Mailing Address - Phone:404-594-9449
Mailing Address - Fax:866-217-7073
Practice Address - Street 1:4145 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-5400
Practice Address - Country:US
Practice Address - Phone:706-869-7373
Practice Address - Fax:706-869-7380
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008880101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA465261225OtherIRS