Healthcare Provider Details

I. General information

NPI: 1750161063
Provider Name (Legal Business Name): KATHRYN MARGARET ANDERSON LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 BARRETT ST
SAINT PAUL MN
55103-1311
US

IV. Provider business mailing address

1008 BARRETT ST
SAINT PAUL MN
55103-1311
US

V. Phone/Fax

Practice location:
  • Phone: 612-381-4363
  • Fax:
Mailing address:
  • Phone: 612-381-4363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305565
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: