MEDICARE: DR. MARIE LYNN ANDERSON PSYD, LP, LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	1701	MN
2	103TC1900X	Counseling Psychologist	5635	MN

General Provider Information

NPI Number	:	1194976407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIE LYNN ANDERSON PSYD, LP, LMFT

Provider Business Mailing Address
First Line	:	12760 ABERDEEN ST NE
Second Line	:	SUITE 212
City	:	BLAINE
State	:	MN
Zip	:	55449-5845
Country	:	US
Telephone Number	:	651-600-2727
Fax Number	:	612-656-3031

Provider Business Practice Location Address
First Line	:	12760 ABERDEEN ST NE
Second Line	:	SUITE 212
City	:	BLAINE
State	:	MN
Zip	:	55449-5845
Country	:	US
Telephone Number	:	651-600-2727
Fax Number	:	612-656-3031

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2008
Last Update Date	:	08/28/2013

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