Provider Demographics
NPI:1093708158
Name:ANDERSON, JOHN PETER (LCSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PETER
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3035
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-0735
Mailing Address - Country:US
Mailing Address - Phone:315-420-2784
Mailing Address - Fax:315-342-6035
Practice Address - Street 1:143 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2225
Practice Address - Country:US
Practice Address - Phone:315-420-2784
Practice Address - Fax:315-342-6035
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070270-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1033Medicare PIN