Basic Information
| Provider Information | |||||||||
| NPI: | 1134365489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | LISSA | ||||||||
| MiddleName: | BROD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROD | ||||||||
| OtherFirstName: | LISSA | ||||||||
| OtherMiddleName: | SIMONE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1802 YAKIMA AVE | ||||||||
| Address2: | STE 208 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539852722 | ||||||||
| FaxNumber: | 2539852853 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 YAKIMA AVE | ||||||||
| Address2: | STE 208 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539852722 | ||||||||
| FaxNumber: | 2539852853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2008 | ||||||||
| LastUpdateDate: | 02/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD29211 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD60222384 | WA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084H0002X | MD60222384 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0284389 | 01 | WA | STATE L&I | OTHER | 0284393 | 01 | WA | STATE L&I | OTHER | 0284399 | 01 | WA | STATE L&I | OTHER |