Provider Demographics
NPI:1417031667
Name:ANDERSON, DAVID MICHAEL (LMFT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LMFT
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 536
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-0536
Mailing Address - Country:US
Mailing Address - Phone:651-257-4406
Mailing Address - Fax:651-257-4406
Practice Address - Street 1:24799 FOREST BLVD
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-7215
Practice Address - Country:US
Practice Address - Phone:651-257-4406
Practice Address - Fax:651-257-4406
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1063106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN96D29ANOtherBLUEPLUS
MN172491OtherUBH
MN96D29ANOtherBLUECROSS BLUESHIELD
MN6274978OtherBHP
MN172491OtherUCARE