Provider Demographics
NPI:1053389270
Name:ANDERSON, SYDNEY F (PHD)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:F
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3871
Mailing Address - Country:US
Mailing Address - Phone:812-331-2800
Mailing Address - Fax:
Practice Address - Street 1:637 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3871
Practice Address - Country:US
Practice Address - Phone:812-331-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040198A103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100331430AMedicaid
000000316234OtherANTHEM
IN227860BMedicare ID - Type Unspecified
000000316234OtherANTHEM