Provider Demographics
NPI:1346975364
Name:ANDERSON, BEVERLY GAY (LPCC, LADC)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:GAY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22273 PETERSON LN
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7072
Mailing Address - Country:US
Mailing Address - Phone:701-306-0315
Mailing Address - Fax:
Practice Address - Street 1:26246 CRANE RD
Practice Address - Street 2:
Practice Address - City:WHITE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56591-9998
Practice Address - Country:US
Practice Address - Phone:218-983-6325
Practice Address - Fax:218-983-3289
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303965101YA0400X
MNCC03438101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)