Healthcare Provider Details

I. General information

NPI: 1306224365
Provider Name (Legal Business Name): MELISSA ANDERSON PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 ELM AVE
MOOSE LAKE MN
55767-7706
US

IV. Provider business mailing address

316 ELM AVE PO BOX 243
MOOSE LAKE MN
55767-7706
US

V. Phone/Fax

Practice location:
  • Phone: 218-485-4445
  • Fax: 218-485-0477
Mailing address:
  • Phone: 218-485-4445
  • Fax: 218-485-0477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5864
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1494
License Number StateMN

VIII. Authorized Official

Name: DR. MELISSA JEAN ANDERSON
Title or Position: PSYCHOLOGIST/OWNER
Credential: PSYD
Phone: 218-485-4445