Healthcare Provider Details

I. General information

NPI: 1366357006
Provider Name (Legal Business Name): TIFFANY NICHOLE ANDERSON MSW,LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

IV. Provider business mailing address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-6422
  • Fax:
Mailing address:
  • Phone: 218-333-6422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number32170
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: