=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669867511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN SCOTT ANDERSON ED.S., LP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2015
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 N MAIN ST STE 205
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55912-3474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-440-0134
-----------------------------------------------------
Fax | 855-748-3132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1914 12TH AVE NE
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55912-4009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-440-0134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | LP3823
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | LP3823
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------