Provider Demographics
NPI:1164872834
Name:ANDERSON, ROLAND EDWARD
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:EDWARD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N AURORA ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2276
Mailing Address - Country:US
Mailing Address - Phone:209-468-8931
Mailing Address - Fax:209-468-8640
Practice Address - Street 1:620 N AURORA ST
Practice Address - Street 2:SUITE 1
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2276
Practice Address - Country:US
Practice Address - Phone:209-468-8931
Practice Address - Fax:209-468-8640
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst