Healthcare Provider Details

I. General information

NPI: 1114504123
Provider Name (Legal Business Name): LISA MARIE ANDERSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 WAYZATA BLVD STE 255
ST LOUIS PARK MN
55416-1275
US

IV. Provider business mailing address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

V. Phone/Fax

Practice location:
  • Phone: 952-525-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6534
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: