Provider Demographics
NPI:1053686857
Name:ANDERSON, BROOKE (PSY D)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 E DIAMOND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1923
Mailing Address - Country:US
Mailing Address - Phone:612-567-6674
Mailing Address - Fax:612-814-0668
Practice Address - Street 1:6 E DIAMOND LAKE RD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1923
Practice Address - Country:US
Practice Address - Phone:612-567-6674
Practice Address - Fax:612-814-0668
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5797103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist