Provider Demographics
NPI:1457392516
Name:ANDERSON, DOROTHY JEAN (PHD)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:JEAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 POPCORN ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-2814
Mailing Address - Country:US
Mailing Address - Phone:503-391-5666
Mailing Address - Fax:503-371-3839
Practice Address - Street 1:2264 MCGILCHRIST ST SE
Practice Address - Street 2:SUITE 100
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1187
Practice Address - Country:US
Practice Address - Phone:503-391-5666
Practice Address - Fax:503-371-3839
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0639103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR117168Medicare UPIN