Provider Demographics
NPI:1356485924
Name:ANDERSON, LARRY L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 DUPONT AVE S STE 202
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2700
Mailing Address - Country:US
Mailing Address - Phone:612-718-0894
Mailing Address - Fax:612-879-0059
Practice Address - Street 1:2124 DUPONT AVE S STE 202
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2700
Practice Address - Country:US
Practice Address - Phone:612-718-0894
Practice Address - Fax:612-879-0059
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4461103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist