1255423695 NPI number — DR. CONRAD ASHTON ANDERSON L.C.S.W., PH.D.

Table of content: DR. CONRAD ASHTON ANDERSON L.C.S.W., PH.D. (NPI 1255423695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255423695 NPI number — DR. CONRAD ASHTON ANDERSON L.C.S.W., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
CONRAD
Provider Middle Name:
ASHTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W., PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255423695
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
739 BUDDELIA CV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BILOXI
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39532-4118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-365-3552
Provider Business Mailing Address Fax Number:
228-392-9743

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1636 POPPS FERRY RD
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
BILOXI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39532-2217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-365-3552
Provider Business Practice Location Address Fax Number:
228-392-9743
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  L.C.S.W. C#3822 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 302I803223 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 030389866 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 06656046 . This is a "MS MEDICAID PROVIDER # 06656046" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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