Provider Demographics
NPI:1396141644
Name:ANDERSEN, GREGORY SR (BA LCDP)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:ANDERSEN
Suffix:SR
Gender:M
Credentials:BA LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813-3143
Mailing Address - Country:US
Mailing Address - Phone:401-789-0934
Mailing Address - Fax:
Practice Address - Street 1:350 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-2494
Practice Address - Country:US
Practice Address - Phone:401-789-0934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00478101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)