Provider Demographics
NPI:1134398480
Name:ANDERSON, ANDRE L (BCBA)
Entity type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1361
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37011-1361
Mailing Address - Country:US
Mailing Address - Phone:615-293-1864
Mailing Address - Fax:
Practice Address - Street 1:4316 SUMMERCREST BLVD APT 514
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-5804
Practice Address - Country:US
Practice Address - Phone:615-293-1864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-04-1884171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor