Provider Demographics
NPI:1518970169
Name:ANDERSON, THOMAS RANDALL (PSYD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RANDALL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3997 STEWART LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-7319
Mailing Address - Country:US
Mailing Address - Phone:866-325-5434
Mailing Address - Fax:866-325-5340
Practice Address - Street 1:103 RUBY LN
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-7341
Practice Address - Country:US
Practice Address - Phone:850-682-1903
Practice Address - Fax:850-682-8689
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical