Provider Demographics
NPI:1245702547
Name:ANDERSON, TRISTEN
Entity type:Individual
Prefix:
First Name:TRISTEN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11048 ALEX DR
Mailing Address - Street 2:
Mailing Address - City:SAUK CENTRE
Mailing Address - State:MN
Mailing Address - Zip Code:56378-4929
Mailing Address - Country:US
Mailing Address - Phone:320-241-6427
Mailing Address - Fax:
Practice Address - Street 1:218 PINE ST S
Practice Address - Street 2:
Practice Address - City:SAUK CENTRE
Practice Address - State:MN
Practice Address - Zip Code:56378-1335
Practice Address - Country:US
Practice Address - Phone:320-351-7807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1094470-1-HCBS171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator