Provider Demographics
NPI:1669491908
Name:ANDERSON, DONNA (LICSW)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 COUNTY ROAD B W
Mailing Address - Street 2:ROSEWOOD OFFICE PLAZA SUITE 210S
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4057
Mailing Address - Country:US
Mailing Address - Phone:651-621-2495
Mailing Address - Fax:651-621-2496
Practice Address - Street 1:1711 COUNTY ROAD B W
Practice Address - Street 2:ROSEWOOD OFFICE PLAZA SUITE 210S
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4057
Practice Address - Country:US
Practice Address - Phone:651-621-2495
Practice Address - Fax:651-621-2496
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-20080OtherUBH
MN0G034ANOtherBC-BS
MN990990570030OtherPREFERRED ONE
MN106222OtherUC
MN658755100Medicaid
MN658755100Medicaid