Healthcare Provider Details

I. General information

NPI: 1720450638
Provider Name (Legal Business Name): NICHOLAS ANDERSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 S SEPULVEDA BLVD APT 206
LOS ANGELES CA
90064-3946
US

IV. Provider business mailing address

2901 S SEPULVEDA BLVD APT 206
LOS ANGELES CA
90064-3946
US

V. Phone/Fax

Practice location:
  • Phone: 916-337-7704
  • Fax:
Mailing address:
  • Phone: 916-337-7704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number27474
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number27474
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number27474
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number27474
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number27474
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number27474
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number27474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: