Basic Information
| Provider Information | |||||||||
| NPI: | 1750381851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2109 S NORTON AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571053730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053342696 | ||||||||
| FaxNumber: | 6053399944 | ||||||||
| Practice Location | |||||||||
| Address1: | 2109 S NORTON AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571053730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053342696 | ||||||||
| FaxNumber: | 6053399944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 106H00000X | 1141 | SD | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103T00000X | 353 | SD | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 6550970 | 05 | SD | MEDICAID | 3059 | 01 | SD | BCBS | OTHER | 21966 | 01 | SIOUX VALLEY | OTHER | 7H877AN | 01 | MN | BCBS | OTHER |