Provider Demographics
NPI:1982716940
Name:ANDERSON, THOMAS (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5019 PLACID PL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-5017
Mailing Address - Country:US
Mailing Address - Phone:512-451-3914
Mailing Address - Fax:
Practice Address - Street 1:1600 W 38TH ST STE 428
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6409
Practice Address - Country:US
Practice Address - Phone:512-454-3685
Practice Address - Fax:512-454-3689
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23592103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00H04ROtherBLUE CROSS
TX611170Medicare ID - Type Unspecified