Provider Demographics
NPI:1598781585
Name:ANDERSON, DAVID MARK (PSY D)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARK
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11022 N 28TH DRIVE
Mailing Address - Street 2:#220
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029
Mailing Address - Country:US
Mailing Address - Phone:602-942-2787
Mailing Address - Fax:602-942-3153
Practice Address - Street 1:11022 N 28TH DRIVE
Practice Address - Street 2:#220
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029
Practice Address - Country:US
Practice Address - Phone:602-942-2787
Practice Address - Fax:602-942-3153
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3042103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical