Basic Information
| Provider Information | |||||||||
| NPI: | 1730130634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | TOM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | EDD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 HENRY CLOWER BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300783152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709789393 | ||||||||
| FaxNumber: | 7709789324 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 HENRY CLOWER BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300783152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709789393 | ||||||||
| FaxNumber: | 7709789324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 001166 | GA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.