Healthcare Provider Details

I. General information

NPI: 1518970169
Provider Name (Legal Business Name): THOMAS RANDALL ANDERSON PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 RUBY LN
CRESTVIEW FL
32539-7341
US

IV. Provider business mailing address

3997 STEWART LAKE RD
CHIPLEY FL
32428-7319
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-1903
  • Fax: 850-682-8689
Mailing address:
  • Phone: 866-325-5434
  • Fax: 866-325-5340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY6519
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: