Healthcare Provider Details

I. General information

NPI: 1275614869
Provider Name (Legal Business Name): TERENCE NEAL ANDERSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 PINE LAKE AVE
LA PORTE IN
46350-3061
US

IV. Provider business mailing address

318 PINE LAKE AVE BOX 668
LAPORTE IN
46352-0668
US

V. Phone/Fax

Practice location:
  • Phone: 219-324-6263
  • Fax: 219-324-6263
Mailing address:
  • Phone: 219-324-6263
  • Fax: 219-324-6263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20010366 HSPP
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20010366 HSPP
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20010366 HSPP
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: