Provider Demographics
NPI:1134552698
Name:ANDERSON, CORY (MS)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 CAMINO DEL RIO S
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3607
Mailing Address - Country:US
Mailing Address - Phone:619-298-8722
Mailing Address - Fax:619-298-5235
Practice Address - Street 1:2333 CAMINO DEL RIO S
Practice Address - Street 2:SUITE 250
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3607
Practice Address - Country:US
Practice Address - Phone:619-298-8722
Practice Address - Fax:619-298-5235
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC53391106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist