Provider Demographics
NPI:1376520130
Name:ANDERSON, DAVID C (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:C
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 1:1420 E COOLEY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3981
Mailing Address - Country:US
Mailing Address - Phone:909-499-5625
Mailing Address - Fax:909-794-2113
Practice Address - Street 1:1420 E COOLEY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3981
Practice Address - Country:US
Practice Address - Phone:909-499-5625
Practice Address - Fax:909-794-2113
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 6215103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical