Provider Demographics
NPI:1376146985
Name:ANDERSON, TIMOTHY P (MA, LADC-S)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MA, LADC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5628 SILAS DENT RD NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-0195
Mailing Address - Country:US
Mailing Address - Phone:651-724-5648
Mailing Address - Fax:
Practice Address - Street 1:3737 40TH AVE NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1772
Practice Address - Country:US
Practice Address - Phone:651-724-5648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304740101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)