MEDICARE: DR. NICHOLAS ANDERSON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0700X	Adult Development & Aging Psychologist	27474	CA
2	103TB0200X	Cognitive & Behavioral Psychologist	27474	CA
3	103TC0700X	Clinical Psychologist	27474	CA
4	103TC2200X	Clinical Child & Adolescent Psychologist	27474	CA
5	103TH0004X	Health Psychologist	27474	CA
6	103TH0100X	Health Service Psychologist	27474	CA
7	103TP2701X	Group Psychotherapy Psychologist	27474	CA

General Provider Information

NPI Number	:	1720450638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS ANDERSON PH.D.

Provider Business Mailing Address
First Line	:	2901 S SEPULVEDA BLVD APT 206
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-3946
Country	:	US
Telephone Number	:	916-337-7704
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 S SEPULVEDA BLVD APT 206
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-3946
Country	:	US
Telephone Number	:	916-337-7704
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2015
Last Update Date	:	10/30/2015

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