Basic Information
| Provider Information | |||||||||
| NPI: | 1053407635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 349 LAKEPORT DR | ||||||||
| Address2: | |||||||||
| City: | SPRING CREEK | ||||||||
| State: | NV | ||||||||
| PostalCode: | 898156048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752999906 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 380 COURT ST | ||||||||
| Address2: | |||||||||
| City: | ELKO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 898013158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157795600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 20065 | TX | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | CP0001 | NV | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 743025435 | 01 | TX | TRICARE | OTHER | NM600035 | 01 | NM | VALUE OPTIONS | OTHER | 100516741 | 05 | NV | MEDICAID | 84839L | 01 | TX | BCBS OF TEXAS | OTHER | 1784936-01 | 05 | TX | MEDICAID |