Provider Demographics
NPI:1033152459
Name:ANDERSON, LYNNE M
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYNNE
Other - Middle Name:
Other - Last Name:WORDEN/BODEIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1011 MILITARY ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5416
Mailing Address - Country:US
Mailing Address - Phone:810-985-8900
Mailing Address - Fax:810-985-7620
Practice Address - Street 1:520 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3838
Practice Address - Country:US
Practice Address - Phone:810-984-4202
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010842961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM97240058Medicare ID - Type Unspecified