Healthcare Provider Details

I. General information

NPI: 1508042920
Provider Name (Legal Business Name): MR. BRAD CHARLES ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 I ST.
DAVIS CA
95616
US

IV. Provider business mailing address

PO BOX 988
DAVIS CA
95616
US

V. Phone/Fax

Practice location:
  • Phone: 530-758-4078
  • Fax: 530-758-1685
Mailing address:
  • Phone: 530-758-4078
  • Fax: 530-758-1685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: