Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PY 60645671 | WA |
Y | 103TC0700X | Clinical Psychologist | PY 60645671 | WA |
NPI | 1003364928 |
---|---|
Provider Name | Derek Ryan Anderson |
First Address | Tacoma, WA 98493-0003 |
Second Address | Tacoma, WA 98493-0003 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2016 |
Last Update Date | 20/09/2016 |