Healthcare Provider Details

I. General information

NPI: 1952477143
Provider Name (Legal Business Name): WENDE J ANDERSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 02/26/2023
Certification Date: 02/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 RIVERVIEW DR
MELBOURNE FL
32901-4711
US

IV. Provider business mailing address

200 N PALM AVE UNIT 33850
INDIALANTIC FL
32903-5034
US

V. Phone/Fax

Practice location:
  • Phone: 321-541-1250
  • Fax: 321-951-1928
Mailing address:
  • Phone: 321-541-1250
  • Fax: 321-951-1928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY7426
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number0810007012
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPY7426
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7426
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: