MEDICARE: LARRY ANDERSON PSYD LLC

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	103T00000X	Psychologist	LP4461	MN

General Provider Information

NPI Number	:	1841796414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LARRY ANDERSON PSYD LLC

Provider Business Mailing Address
First Line	:	2307 CLEVELAND ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-4020
Country	:	US
Telephone Number	:	612-718-0894
Fax Number	:	612-879-0059

Provider Business Practice Location Address
First Line	:	2124 DUPONT AVE S STE 202
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2719
Country	:	US
Telephone Number	:	612-718-0894
Fax Number	:	612-879-0059

Authorized Official
Title or Position	:	OWNER
Name	:	LARRY L ANDERSON
Credential	:	PSYD
Telephone Number	:	612-718-0894

Provider Enumeration Date	:	04/03/2018
Last Update Date	:	06/01/2020

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