Provider Demographics
NPI:1184463473
Name:ANDERSON, JOHANNA TYLER (MED)
Entity type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:TYLER
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MISS
Other - First Name:JOHANNA
Other - Middle Name:MOORE
Other - Last Name:TYLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:709 VIA CASITAS
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1814
Mailing Address - Country:US
Mailing Address - Phone:510-460-2498
Mailing Address - Fax:
Practice Address - Street 1:1109 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1418
Practice Address - Country:US
Practice Address - Phone:415-473-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health