Provider Demographics
NPI:1538924519
Name:ANDERSON, CARMELO ANTHONY
Entity type:Individual
Prefix:
First Name:CARMELO
Middle Name:ANTHONY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5802 OLIVETREE DR APT G3
Mailing Address - Street 2:5802 OLIVETREE DR APT G3
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603
Mailing Address - Country:US
Mailing Address - Phone:989-332-3565
Mailing Address - Fax:
Practice Address - Street 1:2521 N ELMS RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-9423
Practice Address - Country:US
Practice Address - Phone:866-498-3909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIA536108067971106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician