Provider Demographics
NPI:1821128471
Name:BOB ANDERSON, PH.D., PC
Entity Type:Organization
Organization Name:BOB ANDERSON, PH.D., PC
Other - Org Name:SOLUTIONS BY THE LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT-LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-892-5788
Mailing Address - Street 1:710 NORTHEAST DR
Mailing Address - Street 2:SUITE 11
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7427
Mailing Address - Country:US
Mailing Address - Phone:704-892-5788
Mailing Address - Fax:704-892-5799
Practice Address - Street 1:710 NORTHEAST DR
Practice Address - Street 2:SUITE 11
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7427
Practice Address - Country:US
Practice Address - Phone:704-892-5788
Practice Address - Fax:704-892-5799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1891103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC102698OtherMHN
NC6000290Medicaid
NC965120OtherCOVENTRY HC-FIRST HEALTH
NC386715OtherMAMSI
NC101417000OtherMAGELLAN HEALTH SERVICES
NC6165368OtherUNITED BEHAVIORAL HEALTH
NC2339094Medicare ID - Type UnspecifiedGROUP NUMBER
NC386715OtherMAMSI