Provider Demographics
NPI:1083041453
Name:ANDERSON, DARRELL E (HIS)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:E
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 CLEBURNE BLVD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:VA
Mailing Address - Zip Code:24084-4435
Mailing Address - Country:US
Mailing Address - Phone:540-674-4889
Mailing Address - Fax:540-674-1666
Practice Address - Street 1:680 W LEE HWY
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1708
Practice Address - Country:US
Practice Address - Phone:276-228-0866
Practice Address - Fax:540-674-1666
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2101001394237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2101001394OtherSTATE LICENSE