Provider Demographics
NPI:1821412974
Name:ANDERSON, CAROL ROBERTA (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:ROBERTA
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:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95378-0400
Mailing Address - Country:US
Mailing Address - Phone:209-835-4141
Mailing Address - Fax:209-830-3974
Practice Address - Street 1:23500 KASSON RD.,
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95378-0400
Practice Address - Country:US
Practice Address - Phone:209-835-4141
Practice Address - Fax:209-830-3974
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20604103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical