Provider Demographics
NPI:1124405667
Name:ANDERSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 UPPER 183RD ST W
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-8102
Mailing Address - Country:US
Mailing Address - Phone:612-743-0715
Mailing Address - Fax:
Practice Address - Street 1:2103 B COUNTY ROAD D
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109
Practice Address - Country:US
Practice Address - Phone:651-748-5019
Practice Address - Fax:651-773-7591
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN3779106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health