Provider Demographics
NPI:1356413256
Name:ANDERSON, LARRY D (MSW)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 N ANKENY BLVD
Mailing Address - Street 2:SUITE 113
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-4714
Mailing Address - Country:US
Mailing Address - Phone:515-289-9136
Mailing Address - Fax:515-289-9139
Practice Address - Street 1:2525 N ANKENY BLVD
Practice Address - Street 2:SUITE 113
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4714
Practice Address - Country:US
Practice Address - Phone:515-289-9139
Practice Address - Fax:515-189-9139
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB1221OtherPTAN