Provider Demographics
NPI:1104038660
Name:ANDERSON, REBECCA JANE (MA,LP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 THEODORE WIRTH PKWY APT 312
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5341
Mailing Address - Country:US
Mailing Address - Phone:763-591-1845
Mailing Address - Fax:
Practice Address - Street 1:5009 EXCELSIOR BLVD STE 134
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-3049
Practice Address - Country:US
Practice Address - Phone:763-591-1845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3901103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling