Provider Demographics
NPI:1871768762
Name:ANDERSON, VICKY LYN (PSY D)
Entity type:Individual
Prefix:DR
First Name:VICKY
Middle Name:LYN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:DUXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02332
Mailing Address - Country:US
Mailing Address - Phone:508-330-0981
Mailing Address - Fax:
Practice Address - Street 1:45 SOUTH STREET MAILMUN HOUSE
Practice Address - Street 2:BRANDEIS UNIVERSITY PSYCHOLOGICAL COUNSELING CENTER
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453
Practice Address - Country:US
Practice Address - Phone:781-736-3730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6080103TC0700X, 103TH0100X
MA148854103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04898OtherBCBS OF MA