Provider Demographics
NPI:1003214156
Name:ANDERSON, YVETTE
Entity Type:Individual
Prefix:
First Name:YVETTE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:YVETTE
Other - Middle Name:
Other - Last Name:MULFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4481 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9213
Mailing Address - Country:US
Mailing Address - Phone:218-355-8978
Mailing Address - Fax:
Practice Address - Street 1:762 TRANSFER RD STE 21
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1489
Practice Address - Country:US
Practice Address - Phone:218-355-8978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00801101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional