Provider Demographics
NPI:1255636759
Name:ANDERSON, MARY ELLEN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
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 1:1352 310TH AVE
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-4519
Mailing Address - Country:US
Mailing Address - Phone:715-416-2806
Mailing Address - Fax:
Practice Address - Street 1:246 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-8889
Practice Address - Country:US
Practice Address - Phone:715-468-2841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional