Provider Demographics
NPI:1760416390
Name:ANDERSON, RAYMOND GERALD (PHD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:GERALD
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 1:10864 CAROLYN CT
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-4556
Mailing Address - Country:US
Mailing Address - Phone:480-634-7727
Mailing Address - Fax:928-669-3311
Practice Address - Street 1:PARKER INDIAN HEALTH CENTER
Practice Address - Street 2:12033 AGENCY RD
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344
Practice Address - Country:US
Practice Address - Phone:928-669-3373
Practice Address - Fax:928-669-3311
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ638067Medicaid
AZ638067Medicaid
AZP64530Medicare UPIN