Provider Demographics
NPI:1023326857
Name:ANDERSON, LUKE BRITTON
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:BRITTON
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 1:6833 BLYTHEFIELD AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9228
Mailing Address - Country:US
Mailing Address - Phone:626-577-8480
Mailing Address - Fax:616-840-9690
Practice Address - Street 1:235 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5247
Practice Address - Country:US
Practice Address - Phone:616-840-8005
Practice Address - Fax:616-840-9642
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MI6301016865103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor