Basic Information
| Provider Information | |||||||||
| NPI: | 1265028856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | DANIEL | ||||||||
| OtherMiddleName: | BLAKE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BCBA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1212 S AIR DEPOT BLVD STE 17 | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054556868 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1212 S AIR DEPOT BLVD STE 17 | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054556868 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2020 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-21-50229 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103TC1900X | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 225X00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 103TM1800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
No ID Information.