Provider Demographics
NPI:1124007463
Name:ANDERSON, SHIRLEY M (MA CCCA)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8674
Mailing Address - Street 2:1230 E MAIN ST
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1421 PREMIER DR
Practice Address - Street 2:MANKATO CLINIC AT WICKERSHAM CAMPUS
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-14
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6054231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN586515800Medicaid
MNNA2951023870OtherPREFERRED ONE
MN29Q96ANOtherBCBS
MN117664OtherUCARE
640003648OtherRR MEDICARE
MN1758785OtherAMERICAS PPO
MN4511090OtherMEDICA
MNHP40597OtherHEALTH PARTNERS
MN4511090OtherMEDICA