Provider Demographics
NPI:1588901417
Name:ANDERSON, MARIELLEN (LICSW)
Entity type:Individual
Prefix:MS
First Name:MARIELLEN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ROSIE
Other - Middle Name:
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:UNIT 28037 BOX MEDDAC
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09112-8037
Mailing Address - Country:US
Mailing Address - Phone:314-590-3653
Mailing Address - Fax:
Practice Address - Street 1:PSC 454 BOX 1457
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09250-0015
Practice Address - Country:US
Practice Address - Phone:314-590-3653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000082221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical