Healthcare Provider Details

I. General information

NPI: 1316336308
Provider Name (Legal Business Name): JAMES ALLEN ANDERSON LP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5636 LOGAN AVE S
MINNEAPOLIS MN
55419-1512
US

IV. Provider business mailing address

5636 LOGAN AVE S
MINNEAPOLIS MN
55419-1512
US

V. Phone/Fax

Practice location:
  • Phone: 612-226-8324
  • Fax:
Mailing address:
  • Phone: 612-226-8324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLP4117
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: