Provider Demographics
NPI:1548317712
Name:ANDERSON, PHYLLIS MARGO (PSYD)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:MARGO
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 BARNESDALE PATH
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-3900
Mailing Address - Country:US
Mailing Address - Phone:703-803-7450
Mailing Address - Fax:703-830-0001
Practice Address - Street 1:5675 STONE RD
Practice Address - Street 2:SUITE 320
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-1667
Practice Address - Country:US
Practice Address - Phone:703-803-7450
Practice Address - Fax:703-830-0001
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002250103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA086106OtherANTHEM
VAB607OtherBC BS NCA
VAB607OtherBC BS NCA