Provider Demographics
NPI:1720296619
Name:ANDERSON, CAROLYN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
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 1:1011 AUGUSTA DR
Mailing Address - Street 2:#107
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-2062
Mailing Address - Country:US
Mailing Address - Phone:713-914-9944
Mailing Address - Fax:713-914-9599
Practice Address - Street 1:1011 AUGUSTA DR
Practice Address - Street 2:#107
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-2062
Practice Address - Country:US
Practice Address - Phone:713-914-9944
Practice Address - Fax:713-914-9599
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25632103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00101PMedicare ID - Type Unspecified