Provider Demographics
NPI:1730302894
Name:ANOKA PSYCHOLOGICAL SERVICES, PA
Entity Type:Organization
Organization Name:ANOKA PSYCHOLOGICAL SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:763-754-1531
Mailing Address - Street 1:11427 HANSON BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3719
Mailing Address - Country:US
Mailing Address - Phone:763-754-1531
Mailing Address - Fax:763-754-3155
Practice Address - Street 1:11427 HANSON BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3719
Practice Address - Country:US
Practice Address - Phone:763-754-1531
Practice Address - Fax:763-754-3155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3751103T00000X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X
MN78351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
402G3ANOtherBCBS
401G6ANOtherBCBS
110367OtherHEALTH PARTNERS