Provider Demographics
NPI:1669659520
Name:ANDERSON, SONG LOR (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:SONG
Middle Name:LOR
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11205 VIRGINIA AVE. N.
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316
Mailing Address - Country:US
Mailing Address - Phone:763-315-1401
Mailing Address - Fax:763-315-1401
Practice Address - Street 1:11205 VIRGINIA AVE N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3765
Practice Address - Country:US
Practice Address - Phone:763-315-1401
Practice Address - Fax:763-315-1401
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN155211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical