Provider Demographics
NPI:1720351158
Name:DONNA ANDERSON LICSW, PA
Entity Type:Organization
Organization Name:DONNA ANDERSON LICSW, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:651-621-2495
Mailing Address - Street 1:1711 COUNTY ROAD B W
Mailing Address - Street 2: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: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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW 12881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty