Provider Demographics
NPI:1417365057
Name:ADAM ANDERSON, PHD, CLINICAL PSYCHOLOGIST, LLC
Entity Type:Organization
Organization Name:ADAM ANDERSON, PHD, CLINICAL PSYCHOLOGIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:507-340-2011
Mailing Address - Street 1:50 CANTERBURY CT
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-8988
Mailing Address - Country:US
Mailing Address - Phone:507-340-2011
Mailing Address - Fax:
Practice Address - Street 1:11 CIVIC CENTER PLZ STE 201
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7718
Practice Address - Country:US
Practice Address - Phone:507-340-2011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty