Provider Demographics
NPI:1609849025
Name:ANDERSON, J CRAIG I (PHD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:CRAIG
Last Name:ANDERSON
Suffix:I
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 1:500 NE SPANISH RIVER BLVD
Mailing Address - Street 2:28-B
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4515
Mailing Address - Country:US
Mailing Address - Phone:561-241-9210
Mailing Address - Fax:561-241-9210
Practice Address - Street 1:500 NE SPANISH RIVER BLVD
Practice Address - Street 2:28-B
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-4515
Practice Address - Country:US
Practice Address - Phone:561-241-9210
Practice Address - Fax:561-241-9210
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0250104100000X
FL0142106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL588925Medicaid
FLZ1375Medicare ID - Type Unspecified