Provider Demographics
NPI:1194908673
Name:ANDERSON, MARY LU (LCSW, RN, CSAC)
Entity type:Individual
Prefix:
First Name:MARY LU
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW, RN, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5013 E BUCKEYE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2301
Mailing Address - Country:US
Mailing Address - Phone:608-222-8654
Mailing Address - Fax:
Practice Address - Street 1:5013 E BUCKEYE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-2301
Practice Address - Country:US
Practice Address - Phone:608-222-8654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1911-132101YA0400X
WI973-123101YM0800X
WI41435-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39295500Medicaid