Provider Demographics
NPI:1699916288
Name:ANDERSON, ELLEN G (LISAC)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:G
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 CARLISLE DR
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4819
Mailing Address - Country:US
Mailing Address - Phone:703-464-5122
Mailing Address - Fax:
Practice Address - Street 1:457 CARLISLE DR
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4819
Practice Address - Country:US
Practice Address - Phone:703-464-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC0296101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)