Provider Demographics
NPI:1962685339
Name:ANDERSON, REBECCA HERMAN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:HERMAN
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 1:640 JACKSON ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2502
Mailing Address - Country:US
Mailing Address - Phone:651-254-1000
Mailing Address - Fax:651-254-9595
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-1000
Practice Address - Fax:651-254-9595
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-08
Last Update Date:2007-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical