Healthcare Provider Details

I. General information

NPI: 1487596409
Provider Name (Legal Business Name): MARI GWYN ANDERSON FAIRCHILD LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 GREEN OAK DR # 306
MINNETONKA MN
55343-4708
US

IV. Provider business mailing address

5900 GREEN OAK DR # 306
MINNETONKA MN
55343-4708
US

V. Phone/Fax

Practice location:
  • Phone: 952-243-8707
  • Fax: 612-484-3752
Mailing address:
  • Phone: 952-243-8707
  • Fax: 612-484-3752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5770
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number307588
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: