Basic Information
| Provider Information | |||||||||
| NPI: | 1548798192 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | REBECCA | ||||||||
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| Credential: | LLMSW, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FORD PL STE 3A | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482023450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138744806 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172055148 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2017 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801100729 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363A00000X | 1167732 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5601010058 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.