Provider Demographics
NPI:1386739712
Name:ANDERSON, JOHN C (LPC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S SILVER SPRINGS ROAD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703
Mailing Address - Country:US
Mailing Address - Phone:573-334-1100
Mailing Address - Fax:573-651-4345
Practice Address - Street 1:402 S SILVER SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:573-334-1100
Practice Address - Fax:573-651-4345
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002659101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493976401Medicaid
MO10118SWOtherBLUE CROSS BLUE SHIELD
MO469416OtherHEALTHLINK