Provider Demographics
NPI:1679711436
Name:ANDERSON, CHARLES MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARK
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 1:2421 71ST AVENUE CT NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-6451
Mailing Address - Country:US
Mailing Address - Phone:253-549-3822
Mailing Address - Fax:
Practice Address - Street 1:2421 71ST AVENUE CT NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-6451
Practice Address - Country:US
Practice Address - Phone:253-549-3822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-31
Last Update Date:2009-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPSY00001052103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical