Basic Information
| Provider Information | |||||||||
| NPI: | 1174938542 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ADISA | ||||||||
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| Credential: | B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1890 NE MERMAN DR | ||||||||
| Address2: | APT A103 | ||||||||
| City: | PULLMAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991635084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623310808 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2222 BANCROFT WAY | ||||||||
| Address2: | #4300 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947204300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106422000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 06/24/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.