Provider Demographics
NPI:1467534941
Name:ANDERSON, CEDRIC ANTHONY (MFTI)
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:ANTHONY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 S LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-3660
Mailing Address - Country:US
Mailing Address - Phone:209-948-1185
Mailing Address - Fax:
Practice Address - Street 1:2495 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8251
Practice Address - Country:US
Practice Address - Phone:209-465-1080
Practice Address - Fax:209-465-2709
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF43408101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health