Provider Demographics
NPI:1457574527
Name:ANDERSON, PERRY J JR (MSW)
Entity Type:Individual
Prefix:MR
First Name:PERRY
Middle Name:J
Last Name:ANDERSON
Suffix:JR
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 1:440 105TH ST
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-4010
Mailing Address - Country:US
Mailing Address - Phone:715-268-5165
Mailing Address - Fax:
Practice Address - Street 1:100 POLK COUNTY PLZ
Practice Address - Street 2:SUITE 50
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-9071
Practice Address - Country:US
Practice Address - Phone:715-485-8445
Practice Address - Fax:715-485-8490
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6798-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40930200Medicaid
WI1258073OtherARAZ INSURANCE
WI2068111OtherCIGNA INSURANCE
WI338871OtherTRI CARE INSURANCE
WIP 12027501OtherWPPN INSURANCE
WI84 81085OtherMEDICA INSURANCE
WI373595OtherMHN HMC INSURANCE
WI37F39PEOtherBCBS MN INSURANCE
WI1026794OtherPREFERRED ONE INSURANCE
WIP31528Medicare UPIN
WI40930200Medicaid