Provider Demographics
NPI:1568683597
Name:ANDERSON, DAVID ROY (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 W POLK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4328
Mailing Address - Country:US
Mailing Address - Phone:312-942-3549
Mailing Address - Fax:312-942-6952
Practice Address - Street 1:1720 W POLK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4328
Practice Address - Country:US
Practice Address - Phone:312-942-3549
Practice Address - Fax:312-942-6952
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical