Provider Demographics
NPI:1114731478
Name:ANDERSON, DETRICH OMAR (LMHP-R)
Entity type:Individual
Prefix:
First Name:DETRICH
Middle Name:OMAR
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LMHP-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 LIPES CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-1182
Mailing Address - Country:US
Mailing Address - Phone:804-869-9101
Mailing Address - Fax:
Practice Address - Street 1:4200 LIPES CT # A
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-1182
Practice Address - Country:US
Practice Address - Phone:804-869-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704013489101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health