Provider Demographics
NPI:1033138623
Name:ANDERSON, JOHN J (LICSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 24TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-0670
Mailing Address - Country:US
Mailing Address - Phone:507-285-9359
Mailing Address - Fax:
Practice Address - Street 1:124 ELTON HILLS LN NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3567
Practice Address - Country:US
Practice Address - Phone:507-282-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical