Provider Demographics
NPI:1932226826
Name:ANDERSON, TIMOTHY A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 NE BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-4712
Mailing Address - Country:US
Mailing Address - Phone:503-936-5067
Mailing Address - Fax:
Practice Address - Street 1:1626 NE BRYANT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-4712
Practice Address - Country:US
Practice Address - Phone:503-936-5067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPSO17610103T00000X
NE867103T00000X, 103TC0700X
OR2684103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid
OR096511Medicaid
OR022959Medicaid