Provider Demographics
NPI:1770690380
Name:ANDERSEN, DENNIS O (LP)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:O
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NORTHWAY DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1218
Mailing Address - Country:US
Mailing Address - Phone:320-253-4321
Mailing Address - Fax:320-240-8525
Practice Address - Street 1:1500 NORTHWAY DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1218
Practice Address - Country:US
Practice Address - Phone:320-253-4321
Practice Address - Fax:320-240-8525
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN114570OtherUCARE PROVIDER NUMBER
MN1026890OtherPREFERRED ONE PROVIDER NU
MN6220282OtherMEDICA PROVIDER NUMBER
MN114614OtherBHP PROVIDER NUMBER
MN25Q50CEOtherBCBS GROUP NUMBER
MN28Q51ANOtherBCBS PROVIDER NUMBER