Basic Information
| Provider Information | |||||||||
| NPI: | 1558509356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | CHARLOTTE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | RAINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 220 RUSKIN DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809102522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726340 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 179 PARKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726300 | ||||||||
| FaxNumber: | 7195726399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2009 | ||||||||
| LastUpdateDate: | 02/02/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.