Provider Demographics
NPI:1477185346
Name:ANDERSON, RANDOLPH (LADC)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5645 LINDSAY ST
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4627
Mailing Address - Country:US
Mailing Address - Phone:763-331-5167
Mailing Address - Fax:
Practice Address - Street 1:5645 LINDSAY ST
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4627
Practice Address - Country:US
Practice Address - Phone:763-331-5167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305346101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)