Provider Demographics
NPI:1902994262
Name:GANDERSON, STEPHEN CARL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CARL
Last Name:GANDERSON
Suffix:
Gender:M
Credentials:PSYD
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 2739
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23327-2739
Mailing Address - Country:US
Mailing Address - Phone:757-548-9996
Mailing Address - Fax:757-382-5085
Practice Address - Street 1:505 CEDAR RD
Practice Address - Street 2:SUITE B-1
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-5585
Practice Address - Country:US
Practice Address - Phone:757-548-9996
Practice Address - Fax:757-382-5085
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001638103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7704755Medicaid
VAR64191Medicare UPIN