Healthcare Provider Details

I. General information

NPI: 1184842833
Provider Name (Legal Business Name): MR. THEODORE EDWARD ANDERSON IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1839 S EL DORADO ST
STOCKTON CA
95206-2025
US

IV. Provider business mailing address

1191 BRIDGETON AVE
MANTECA CA
95336-2938
US

V. Phone/Fax

Practice location:
  • Phone: 209-463-0872
  • Fax:
Mailing address:
  • Phone: 209-346-4034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: