Provider Demographics
NPI:1215707690
Name:ANDERSON, ASA MAURICE
Entity type:Individual
Prefix:
First Name:ASA
Middle Name:MAURICE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14624 SHERMAN WAY STE 508
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2289
Mailing Address - Country:US
Mailing Address - Phone:818-901-4830
Mailing Address - Fax:
Practice Address - Street 1:14624 SHERMAN WAY STE 508
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2289
Practice Address - Country:US
Practice Address - Phone:818-908-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 225400000X
CA145728106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist