Provider Demographics
NPI:1649372590
Name:ANDERSON, MARK ERIC (MA LP LMFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ERIC
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MA LP LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 LONG LAKE RD
Mailing Address - Street 2:SUITE 320 ARDEN WOODS PSYCHOLOGICAL SERVICES
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6428
Mailing Address - Country:US
Mailing Address - Phone:651-482-9361
Mailing Address - Fax:651-482-9888
Practice Address - Street 1:900 LONG LAKE RD
Practice Address - Street 2:SUITE 320 ARDEN WOODS PSYCHOLOGICAL SERVICES
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6428
Practice Address - Country:US
Practice Address - Phone:651-482-9361
Practice Address - Fax:651-482-9888
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1064106H00000X
MNLP 3081103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist