Provider Demographics
NPI:1083655021
Name:ANDERSON, DONALD (LCSW)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:DON
Other - Middle Name:L
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4001 KNIGHTS BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-1743
Mailing Address - Country:US
Mailing Address - Phone:405-573-9905
Mailing Address - Fax:405-573-0404
Practice Address - Street 1:5725 S ROSS AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-5650
Practice Address - Country:US
Practice Address - Phone:405-685-4791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00257069OtherMEDICARE RR
243527302Medicare ID - Type Unspecified