Provider Demographics
NPI:1407339005
Name:ANDERSON, KATHLEEN GEHRING
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GEHRING
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4746 CLEARWATER CIR
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-5623
Mailing Address - Country:US
Mailing Address - Phone:952-440-2485
Mailing Address - Fax:
Practice Address - Street 1:3033 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4688
Practice Address - Country:US
Practice Address - Phone:612-547-9990
Practice Address - Fax:651-925-0427
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01976101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health