Provider Demographics
NPI:1073841771
Name:ANDERSON, JUSTIN ELLIOT (MA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ELLIOT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 NW EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3517
Mailing Address - Country:US
Mailing Address - Phone:503-226-4060
Mailing Address - Fax:
Practice Address - Street 1:709 NW EVERETT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3517
Practice Address - Country:US
Practice Address - Phone:503-226-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ92069ZOtherSANTA CRUZ COUNTY MHSAS GROUP PTAN#