Provider Demographics
NPI:1962976613
Name:ANDERSON, CONNIE L (LPC)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ASBURY CIR STE A
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1397
Mailing Address - Country:US
Mailing Address - Phone:601-264-7079
Mailing Address - Fax:601-296-7819
Practice Address - Street 1:105 ASBURY CIR STE A
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1397
Practice Address - Country:US
Practice Address - Phone:601-264-7079
Practice Address - Fax:601-296-7819
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2346101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional