Provider Demographics
NPI:1083803076
Name:ANDERSON, CLYDE WAYNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:WAYNE
Last Name:ANDERSON
Suffix:
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 1:3424 MONITOR LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-1516
Mailing Address - Country:US
Mailing Address - Phone:850-556-6974
Mailing Address - Fax:
Practice Address - Street 1:3424 MONITOR LN
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-1516
Practice Address - Country:US
Practice Address - Phone:850-556-6974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2013-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6257103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical