Provider Demographics
NPI:1174654917
Name:ANDERSON, KEITH JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:JOHN
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 1:320A ELSMERE AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-9702
Mailing Address - Country:US
Mailing Address - Phone:518-439-1101
Mailing Address - Fax:
Practice Address - Street 1:110 8TH ST.
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180
Practice Address - Country:US
Practice Address - Phone:518-276-6479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0130081103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling