Provider Demographics
NPI:1720293475
Name:ANDERSON, ALISA C (MED, MT-BC)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MED, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6510 EVERGREEN LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6142
Mailing Address - Country:US
Mailing Address - Phone:763-504-7446
Mailing Address - Fax:763-504-8970
Practice Address - Street 1:8301 47TH AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-4512
Practice Address - Country:US
Practice Address - Phone:763-504-7446
Practice Address - Fax:763-504-8970
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist