Provider Demographics
NPI:1053464016
Name:ANDERSON, LAUREL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9911 W PICO BLVD
Mailing Address - Street 2:1070
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2703
Mailing Address - Country:US
Mailing Address - Phone:310-826-9576
Mailing Address - Fax:
Practice Address - Street 1:9911 W PICO BLVD
Practice Address - Street 2:1070
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2703
Practice Address - Country:US
Practice Address - Phone:310-826-9576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9217103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP9217Medicare ID - Type Unspecified