Provider Demographics
NPI:1265028856
Name:ANDERSON, DANIEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:BLAKE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA
Mailing Address - Street 1:1212 S AIR DEPOT BLVD STE 17
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4860
Mailing Address - Country:US
Mailing Address - Phone:405-455-6868
Mailing Address - Fax:
Practice Address - Street 1:1212 S AIR DEPOT BLVD STE 17
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4860
Practice Address - Country:US
Practice Address - Phone:405-455-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-21-50229103K00000X
103K00000X, 103TC1900X, 225X00000X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist