Provider Demographics
NPI:1790157469
Name:ANDERSON, GREG (LP)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:
Last Name:ANDERSON
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 1:410 JOHNSON PKWY
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54015-9678
Mailing Address - Country:US
Mailing Address - Phone:715-497-7230
Mailing Address - Fax:715-600-9023
Practice Address - Street 1:410 JOHNSON PKWY
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:WI
Practice Address - Zip Code:54015-9678
Practice Address - Country:US
Practice Address - Phone:715-497-7230
Practice Address - Fax:715-600-9023
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5932103T00000X
WI3349-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist