=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922940709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BREANNA ANDERSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2026
-----------------------------------------------------
Last Update Date | 04/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 N AMERICAN ST
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95202-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-787-9727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1109 W LOCUST ST
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95240-1822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-294-8085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 230213958
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------