Provider Demographics
NPI:1780834390
Name:ANDERSON, JUSTIN O'NEAL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:O'NEAL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:PSYCH,
Other - Middle Name:
Other - Last Name:INC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1015 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-3207
Mailing Address - Country:US
Mailing Address - Phone:502-272-9718
Mailing Address - Fax:
Practice Address - Street 1:1015 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-3207
Practice Address - Country:US
Practice Address - Phone:502-272-9718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY1732103T00000X
AL1723103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
46-2967720OtherTAX ID