Provider Demographics
NPI:1447560222
Name:ANDERSON, ANDERO
Entity Type:Individual
Prefix:
First Name:ANDERO
Middle Name:
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 1:4262 BLUE DIAMOND RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-7789
Mailing Address - Country:US
Mailing Address - Phone:702-497-3472
Mailing Address - Fax:
Practice Address - Street 1:4443 SUN VISTA DR.
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104
Practice Address - Country:US
Practice Address - Phone:702-685-7918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV263707565Medicaid