Provider Demographics
NPI:1447668108
Name:ANDERSEN, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 WILSON AVE NE STE 110
Mailing Address - Street 2:PO BOX 6069
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-0440
Mailing Address - Country:US
Mailing Address - Phone:320-251-7700
Mailing Address - Fax:320-251-8898
Practice Address - Street 1:22 WILSON AVE NE STE 110
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-0440
Practice Address - Country:US
Practice Address - Phone:320-251-7700
Practice Address - Fax:320-251-8898
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1995106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist