Provider Demographics
NPI:1952455123
Name:ANDERSON, MARK BRIAN (EDD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:BRIAN
Last Name:ANDERSON
Suffix:
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 1:29260 FRANKLIN RD
Mailing Address - Street 2:STE 110
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1196
Mailing Address - Country:US
Mailing Address - Phone:248-722-1652
Mailing Address - Fax:248-485-6798
Practice Address - Street 1:29260 FRANKLIN RD
Practice Address - Street 2:STE 110
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1196
Practice Address - Country:US
Practice Address - Phone:248-722-1652
Practice Address - Fax:248-485-6798
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011646103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist