Provider Demographics
NPI:1275612764
Name:ANDERSON, JUDITH A POPP (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:A POPP
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:JUDITH
Other - Middle Name:ANN
Other - Last Name:POPP-ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:PO BOX 1246
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-1246
Mailing Address - Country:US
Mailing Address - Phone:507-377-5448
Mailing Address - Fax:507-377-5498
Practice Address - Street 1:203 W CLARK ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2549
Practice Address - Country:US
Practice Address - Phone:507-377-5440
Practice Address - Fax:507-377-5498
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300662101YA0400X
MN074871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1011650OtherPREFERRED ONE
MN0G631-POOtherBLUE CROSS/BLUE SHIELD
62-79619OtherUBH