Basic Information
| Provider Information | |||||||||
| NPI: | 1255800322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | NEAL | ||||||||
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| NameSuffix: | |||||||||
| Credential: | CIT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 624 CONNELL PARK LN | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708066534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253004850 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11408 LAKE SHERWOOD AVE N STE A | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708160421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252617143 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2018 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 4018 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 8050569 | 05 | LA | MEDICAID |