Healthcare Provider Details

I. General information

NPI: 1033138623
Provider Name (Legal Business Name): JOHN J ANDERSON LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 ELTON HILLS LN NW
ROCHESTER MN
55901-3567
US

IV. Provider business mailing address

2522 24TH ST NW
ROCHESTER MN
55901-0670
US

V. Phone/Fax

Practice location:
  • Phone: 507-282-1009
  • Fax:
Mailing address:
  • Phone: 507-285-9359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3178
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: