Basic Information
| Provider Information | |||||||||
| NPI: | 1043307697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSEN | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 S BROADWAY STE 18 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018578500 | ||||||||
| FaxNumber: | 7018578555 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 S BROADWAY STE 18 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018578500 | ||||||||
| FaxNumber: | 7018578555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 12/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 1457 | ND | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 1457 | ND | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 54517 | 05 | ND | MEDICAID |