Provider Demographics
NPI:1720593841
Name:ANDREA ANDERSON PSYD LP LLC
Entity Type:Organization
Organization Name:ANDREA ANDERSON PSYD LP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD LP
Authorized Official - Phone:612-963-7027
Mailing Address - Street 1:1826 WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2434
Mailing Address - Country:US
Mailing Address - Phone:612-963-7027
Mailing Address - Fax:
Practice Address - Street 1:4660 SLATER RD STE 245-C
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-4047
Practice Address - Country:US
Practice Address - Phone:612-963-7027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5161103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1659604874Medicaid