Provider Demographics
NPI:1437714847
Name:ANDERSON, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
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 1:1125 11TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-2411
Mailing Address - Country:US
Mailing Address - Phone:320-250-1084
Mailing Address - Fax:
Practice Address - Street 1:150 10TH ST NW STE 2
Practice Address - Street 2:
Practice Address - City:MILACA
Practice Address - State:MN
Practice Address - Zip Code:56353-1737
Practice Address - Country:US
Practice Address - Phone:320-983-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19081101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health