Provider Demographics
NPI:1063851939
Name:ANDERSON, ERIC KENNETH JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:KENNETH
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5838 EDISON PL STE 100
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-5520
Mailing Address - Country:US
Mailing Address - Phone:888-307-0893
Mailing Address - Fax:
Practice Address - Street 1:5838 EDISON PL STE 100
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-5520
Practice Address - Country:US
Practice Address - Phone:888-307-0893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CA28391103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist