Provider Demographics
NPI:1811280704
Name:ANDERSON, TEX W JR (TRADITIONAL PRACTITI)
Entity type:Individual
Prefix:
First Name:TEX
Middle Name:W
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:TRADITIONAL PRACTITI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1144
Mailing Address - Street 2:
Mailing Address - City:CROWNPOINT
Mailing Address - State:NM
Mailing Address - Zip Code:87313-1144
Mailing Address - Country:US
Mailing Address - Phone:505-786-2111
Mailing Address - Fax:505-786-2020
Practice Address - Street 1:2314 SOUTHWEST HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87313
Practice Address - Country:US
Practice Address - Phone:505-786-2111
Practice Address - Fax:505-786-2020
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM860092335OtherBEHAVIORAL HEALTH SERVICE