Provider Demographics
NPI:1447087085
Name:ANDERSON, ANDREZA LOVE (MS)
Entity type:Individual
Prefix:
First Name:ANDREZA
Middle Name:LOVE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 MAYFAIR WAY APT 206
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2045
Mailing Address - Country:US
Mailing Address - Phone:321-362-9515
Mailing Address - Fax:
Practice Address - Street 1:1802 S FISKE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3007
Practice Address - Country:US
Practice Address - Phone:321-446-2113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH26371101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health