Basic Information
| Provider Information | |||||||||
| NPI: | 1104331552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | SAVANNAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10175 FORTUNE PKWY UNIT 903 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045380713 | ||||||||
| FaxNumber: | 9045380714 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 INDUSTRIAL DR STE E | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315584436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045380713 | ||||||||
| FaxNumber: | 9045380714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2017 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-17-30465 | N | 103K00000X | 1-21-53069 | GA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.