Healthcare Provider Details

I. General information

NPI: 1730302894
Provider Name (Legal Business Name): ANOKA PSYCHOLOGICAL SERVICES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11427 HANSON BLVD NW
COON RAPIDS MN
55433-3719
US

IV. Provider business mailing address

11427 HANSON BLVD NW
COON RAPIDS MN
55433-3719
US

V. Phone/Fax

Practice location:
  • Phone: 763-754-1531
  • Fax: 763-754-3155
Mailing address:
  • Phone: 763-754-1531
  • Fax: 763-754-3155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3751
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number3751
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3751
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3751
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3751
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number3751
License Number StateMN
# 7
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7835
License Number StateMN

VIII. Authorized Official

Name: DIANNE M GORDON
Title or Position: CEO
Credential: LICSW
Phone: 763-754-1531