Healthcare Provider Details

I. General information

NPI: 1275558694
Provider Name (Legal Business Name): KEITH J ANDERSEN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 PIONEER LN STE H
BISHOP CA
93514-2563
US

IV. Provider business mailing address

PO BOX 873
BISHOP CA
93515-0873
US

V. Phone/Fax

Practice location:
  • Phone: 760-873-6712
  • Fax: 760-873-6712
Mailing address:
  • Phone: 760-873-6712
  • Fax: 760-873-6712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number14114
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: