MEDICARE: REBECCA JANE ANDERSON MA,LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	LP3901	MN

General Provider Information

NPI Number	:	1104038660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA JANE ANDERSON MA,LP

Provider Business Mailing Address
First Line	:	501 THEODORE WIRTH PKWY APT 312
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-5341
Country	:	US
Telephone Number	:	763-591-1845
Fax Number	:

Provider Business Practice Location Address
First Line	:	5009 EXCELSIOR BLVD STE 134
Second Line	:
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-3049
Country	:	US
Telephone Number	:	763-591-1845
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/08/2007

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