Provider Demographics
NPI:1730130634
Name:ANDERSON, TOM A JR (EDD)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:A
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 HENRY CLOWER BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3152
Mailing Address - Country:US
Mailing Address - Phone:770-978-9393
Mailing Address - Fax:770-978-9324
Practice Address - Street 1:2301 HENRY CLOWER BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3152
Practice Address - Country:US
Practice Address - Phone:770-978-9393
Practice Address - Fax:770-978-9324
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001166103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS41116Medicare UPIN
GA68BBGXGMedicare PIN