Healthcare Provider Details

I. General information

NPI: 1104038660
Provider Name (Legal Business Name): REBECCA JANE ANDERSON MA,LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5009 EXCELSIOR BLVD STE 134
SAINT LOUIS PARK MN
55416-3049
US

IV. Provider business mailing address

501 THEODORE WIRTH PKWY APT 312
GOLDEN VALLEY MN
55422-5341
US

V. Phone/Fax

Practice location:
  • Phone: 763-591-1845
  • Fax:
Mailing address:
  • Phone: 763-591-1845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP3901
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: