Provider Demographics
NPI:1902972797
Name:ANDERSON, SALLY W (LCPC)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 GOLF CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-9208
Mailing Address - Country:US
Mailing Address - Phone:217-356-3979
Mailing Address - Fax:
Practice Address - Street 1:502 W CLARK ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4600
Practice Address - Country:US
Practice Address - Phone:217-355-4450
Practice Address - Fax:217-355-4450
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional