Provider Demographics
NPI:1003884701
Name:ANDERSON, PAUL A (DED)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 W MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:LYKENS
Mailing Address - State:PA
Mailing Address - Zip Code:17048-8823
Mailing Address - Country:US
Mailing Address - Phone:717-365-7777
Mailing Address - Fax:717-365-3848
Practice Address - Street 1:614 MAIN ST
Practice Address - Street 2:
Practice Address - City:LYKENS
Practice Address - State:PA
Practice Address - Zip Code:17048-1309
Practice Address - Country:US
Practice Address - Phone:717-365-7777
Practice Address - Fax:717-365-3848
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA19815703103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01579002Medicaid
PAR70638Medicare UPIN
PA443919Medicare ID - Type Unspecified