Provider Demographics
NPI:1720065345
Name:ANDERS GOBAR, MARY ANN (MA, LP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:ANDERS GOBAR
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 TWELVE OAKS CENTER DR
Mailing Address - Street 2:SUITE 734
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-4401
Mailing Address - Country:US
Mailing Address - Phone:952-406-1710
Mailing Address - Fax:
Practice Address - Street 1:700 TWELVE OAKS CENTER DR
Practice Address - Street 2:SUITE 734
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4401
Practice Address - Country:US
Practice Address - Phone:952-406-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3976103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN857725100Medicaid