Provider Demographics
NPI:1235478660
Name:ANDERSON, JAMES D
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
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 1:58945 BUSINESS CENTER DR STE D
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-7310
Mailing Address - Country:US
Mailing Address - Phone:760-228-9657
Mailing Address - Fax:760-365-2072
Practice Address - Street 1:58945 BUSINESS CENTER DR STE D
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7310
Practice Address - Country:US
Practice Address - Phone:760-228-9657
Practice Address - Fax:760-365-2072
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X
CA85924171M00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator