Provider Demographics
NPI:1912992777
Name:ANDERSON, ROBERT J (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHD
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 538622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8622
Mailing Address - Country:US
Mailing Address - Phone:910-794-4521
Mailing Address - Fax:877-364-7056
Practice Address - Street 1:3205 RANDALL PKWY STE 105
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2565
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:888-746-1787
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1891103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101417000OtherMAGELLAN HEALTH SERVICES
NC102698OtherMHN
NC965120OtherCOVENTRY HC-FIRST HEALTH
NC386715OtherMAMSI
NC6000290Medicaid
NC6165368OtherUNITED BEHAVIORAL HEALTH
NC386715OtherMAMSI