Basic Information
Provider Information | |||||||||
NPI: | 1538351457 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERSON | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S., QMHP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 37875 JASPER LOWELL RD | ||||||||
Address2: |   | ||||||||
City: | JASPER | ||||||||
State: | OR | ||||||||
PostalCode: | 974389751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417471235 | ||||||||
FaxNumber: | 5417474722 | ||||||||
Practice Location | |||||||||
Address1: | 37875 JASPER LOWELL RD | ||||||||
Address2: |   | ||||||||
City: | JASPER | ||||||||
State: | OR | ||||||||
PostalCode: | 974389751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417471235 | ||||||||
FaxNumber: | 5417474722 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2007 | ||||||||
LastUpdateDate: | 08/14/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0807X | R.N.023078 | OR | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent |
No ID Information.