Provider Demographics
NPI:1467916155
Name:ANDERSON, KRISTINA LORRAINE
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LORRAINE
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 1:3564 ROLLING VIEW DR STE B
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7003
Mailing Address - Country:US
Mailing Address - Phone:651-777-6536
Mailing Address - Fax:651-777-6536
Practice Address - Street 1:3564 ROLLING VIEW DR STE B
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-7003
Practice Address - Country:US
Practice Address - Phone:651-777-6536
Practice Address - Fax:651-777-6536
Is Sole Proprietor?:No
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3680101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health