Provider Demographics
NPI:1962168716
Name:ANDERSON, MICHAEL LOUIS JR (LCSW-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LOUIS
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 POTOMAC RD
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085-4825
Mailing Address - Country:US
Mailing Address - Phone:443-905-6795
Mailing Address - Fax:
Practice Address - Street 1:539 POTOMAC RD
Practice Address - Street 2:
Practice Address - City:JOPPA
Practice Address - State:MD
Practice Address - Zip Code:21085-4825
Practice Address - Country:US
Practice Address - Phone:443-905-6795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD243261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1962168716Medicaid
MD88-2746653OtherWILDERNESS THERAPY