Basic Information
| Provider Information | |||||||||
| NPI: | 1225215122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 SE 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557444201 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1215 SE 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557444201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183271105 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
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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 | 101YA0400X | 302045 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 84-10374 | 01 | MN | UBH | OTHER | 1021875 | 01 | MN | PREFERRED ONE | OTHER | 8199PNO | 01 | MS | BCBS | OTHER |