Provider Demographics
NPI:1548777451
Name:ANDERSON, ISHAEL
Entity Type:Individual
Prefix:
First Name:ISHAEL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7103 CHINABERRY RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75249-1210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1330 RIVER BEND DR STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4934
Practice Address - Country:US
Practice Address - Phone:214-333-7076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-17-46122106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician