MEDICARE: DR. JUSTIN O'NEAL ANDERSON PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	103T00000X	Psychologist	1732	KY
3	103TC0700X	Clinical Psychologist	1723	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46-2967720	OTHER		TAX ID

General Provider Information

NPI Number	:	1780834390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN O'NEAL ANDERSON PSY.D.

Provider Business Mailing Address
First Line	:	1015 S 4TH ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40203-3207
Country	:	US
Telephone Number	:	502-272-9718
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 S 4TH ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40203-3207
Country	:	US
Telephone Number	:	502-272-9718
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2008
Last Update Date	:	06/29/2021

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