Provider Demographics
NPI:1174698989
Name:ANDERSON, MICHAEL (PSYD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1552 CAMINO DEL MAR
Mailing Address - Street 2:UNIT 417
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-2466
Mailing Address - Country:US
Mailing Address - Phone:619-871-1094
Mailing Address - Fax:858-724-1448
Practice Address - Street 1:1552 CAMINO DEL MAR
Practice Address - Street 2:UNIT 417
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-2466
Practice Address - Country:US
Practice Address - Phone:619-871-1094
Practice Address - Fax:858-724-1448
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18109103TC0700X, 103T00000X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic