Provider Demographics
NPI:1285260737
Name:ANDERSON, DEMETRIUS (ASW)
Entity type:Individual
Prefix:MR
First Name:DEMETRIUS
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 MIDDLE FORK PL
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-2623
Mailing Address - Country:US
Mailing Address - Phone:614-571-2065
Mailing Address - Fax:
Practice Address - Street 1:TELECARE CORPORATION IHOT
Practice Address - Street 2:1660 HOTEL CIRCLE NORTH, SUITE 101
Practice Address - City:SAN DEIGO
Practice Address - State:CA
Practice Address - Zip Code:92108
Practice Address - Country:US
Practice Address - Phone:619-961-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW93778101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNONE