Provider Demographics
NPI:1750161063
Name:ANDERSON, KATHRYN MARGARET (LADC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARGARET
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 BARRETT ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-1311
Mailing Address - Country:US
Mailing Address - Phone:612-381-4363
Mailing Address - Fax:
Practice Address - Street 1:1008 BARRETT ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-1311
Practice Address - Country:US
Practice Address - Phone:612-381-4363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305565101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)