Provider Demographics
NPI:1104370683
Name:ANDERSON, TAIT
Entity Type:Individual
Prefix:
First Name:TAIT
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1772 STEIGER LAKE LN
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386-7723
Mailing Address - Country:US
Mailing Address - Phone:952-443-9888
Mailing Address - Fax:952-443-9804
Practice Address - Street 1:8758 EGAN DR
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2561
Practice Address - Country:US
Practice Address - Phone:952-443-9888
Practice Address - Fax:952-443-9804
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9497235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN001442700Medicaid
MN16154051OtherPT CARE
MN565581028804OtherPREFERRED ONE
MN017J6KIOtherBCBS
MN1311578OtherARAZ/AMERICA'S PPO/CIGNA
MN169036OtherUCARE
MN76842OtherHEALTH PARTNERS