Provider Demographics
NPI:1528284718
Name:ANDERSON, DENNIS ROBERT (MA LPC CACIII)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:ROBERT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MA LPC CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N WAHSATCH AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3481
Mailing Address - Country:US
Mailing Address - Phone:719-447-9800
Mailing Address - Fax:
Practice Address - Street 1:223 N WAHSATCH AVE STE 202
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3481
Practice Address - Country:US
Practice Address - Phone:719-447-9800
Practice Address - Fax:719-447-1994
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2748101YA0400X
CO387101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO286060Medicaid