Provider Demographics
NPI:1457085771
Name:ANDERSON, JOHN ARTHUR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ARTHUR
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 1:2432 W. PEORIA AVENUE
Mailing Address - Street 2:BUILDING 5, SUITE 1114
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029
Mailing Address - Country:US
Mailing Address - Phone:602-661-7488
Mailing Address - Fax:
Practice Address - Street 1:2432 W. PEORIA AVENUE
Practice Address - Street 2:BUILDING 5, SUITE 1114
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029
Practice Address - Country:US
Practice Address - Phone:602-661-7488
Practice Address - Fax:602-661-7499
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ172A00000X, 175T00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172A00000XOther Service ProvidersDriver
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZY99000179OtherARIZONA MOTOR VEHICLE DIVISION