Provider Demographics
NPI:1376040105
Name:ANDERSON, DONAL M (LSW)
Entity Type:Individual
Prefix:
First Name:DONAL
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LSW
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 3106
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-3106
Mailing Address - Country:US
Mailing Address - Phone:701-239-6775
Mailing Address - Fax:
Practice Address - Street 1:1010 2ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8226
Practice Address - Country:US
Practice Address - Phone:701-239-6775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5272104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker