Provider Demographics
NPI:1679578686
Name:ANDERSON, RONALD DOUGLAS (PHD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DOUGLAS
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 301
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-0301
Mailing Address - Country:US
Mailing Address - Phone:860-487-1641
Mailing Address - Fax:860-456-4068
Practice Address - Street 1:21 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2644
Practice Address - Country:US
Practice Address - Phone:860-456-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0600001296CT03OtherANTHEM /BLUE CROSS