Provider Demographics
NPI:1932492907
Name:ANDERSEN, KELLY (LADC, LPCC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:LADC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 3RD AVE SW
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-1443
Mailing Address - Country:US
Mailing Address - Phone:320-237-4227
Mailing Address - Fax:
Practice Address - Street 1:645 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1443
Practice Address - Country:US
Practice Address - Phone:320-237-4227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1372101YM0800X
MN302405101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)