Provider Demographics
NPI:1366680696
Name:ANDERSON, STEPHEN RUSSELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RUSSELL
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 1:8297 OLD POST RD E
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-1530
Mailing Address - Country:US
Mailing Address - Phone:716-741-3477
Mailing Address - Fax:
Practice Address - Street 1:8297 OLD POST RD E
Practice Address - Street 2:
Practice Address - City:EAST AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14051-1530
Practice Address - Country:US
Practice Address - Phone:716-741-3477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-00-0220103K00000X
NY#012484 DUP103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst