Healthcare Provider Details

I. General information

NPI: 1699965269
Provider Name (Legal Business Name): MR. SCOTT ERIC ANDERSON I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2239 BRIDGEPORT WAT
MARTRINEZ CA
94553
US

IV. Provider business mailing address

2239 BRIDGEPORT WAY
MARTINEZ CA
94553-6712
US

V. Phone/Fax

Practice location:
  • Phone: 925-957-0456
  • Fax:
Mailing address:
  • Phone: 925-957-0456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number69
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: