Provider Demographics
NPI:1609825785
Name:ANDERSON, DEBRA ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
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:PO BOX 347
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-0347
Mailing Address - Country:US
Mailing Address - Phone:417-777-5314
Mailing Address - Fax:417-777-5320
Practice Address - Street 1:1459 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2950
Practice Address - Country:US
Practice Address - Phone:417-777-5314
Practice Address - Fax:417-777-5320
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005038008103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499186211Medicaid