=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225658339
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WADE BRIAN ANDERSON PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2020
-----------------------------------------------------
Last Update Date | 04/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 GRANDVIEW AVE
-----------------------------------------------------
City | PLEASANTVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10570-2035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-564-8167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 GRANDVIEW AVE
-----------------------------------------------------
City | PLEASANTVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10570-2035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-564-8167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TF0000X
-----------------------------------------------------
Taxonomy Name | Family Psychologist
-----------------------------------------------------
License Number | 013637-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TP0814X
-----------------------------------------------------
Taxonomy Name | Psychoanalysis Psychologist
-----------------------------------------------------
License Number | 013637-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 013637-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------