Provider Demographics
NPI:1659993970
Name:ANDERSON, BENTLY JAMES WATANABE
Entity Type:Individual
Prefix:MR
First Name:BENTLY
Middle Name:JAMES WATANABE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39155 LIBERTY ST STE E500
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1516
Mailing Address - Country:US
Mailing Address - Phone:510-574-2100
Mailing Address - Fax:
Practice Address - Street 1:39155 LIBERTY ST STE E500
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1516
Practice Address - Country:US
Practice Address - Phone:510-574-2100
Practice Address - Fax:510-574-2105
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health