Provider Demographics
NPI:1760919419
Name:ANDERSON, LILY (LICSW)
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:
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 1:130 WABASHA ST S
Mailing Address - Street 2:SUITE 90
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1819
Mailing Address - Country:US
Mailing Address - Phone:651-291-0067
Mailing Address - Fax:651-450-2221
Practice Address - Street 1:130 WABASHA ST S
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1819
Practice Address - Country:US
Practice Address - Phone:651-291-0067
Practice Address - Fax:651-450-2221
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN23525OtherLICSW