Provider Demographics
NPI:1598445256
Name:ANDERSON, ALYSSUM MERYL (LMFT)
Entity Type:Individual
Prefix:
First Name:ALYSSUM
Middle Name:MERYL
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 IDAHO AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2232
Mailing Address - Country:US
Mailing Address - Phone:612-298-4601
Mailing Address - Fax:
Practice Address - Street 1:1114 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2628
Practice Address - Country:US
Practice Address - Phone:651-829-3568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4034106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist