1366401481 NPI number — MRS. BRENDA MELISSIA ANDERSON LICSW

Table of content: MRS. BRENDA MELISSIA ANDERSON LICSW (NPI 1366401481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366401481 NPI number — MRS. BRENDA MELISSIA ANDERSON LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
BRENDA
Provider Middle Name:
MELISSIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MACK
Provider Other First Name:
BRENDA
Provider Other Middle Name:
MELISSIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366401481
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603
Provider Second Line Business Mailing Address:
603 BRUCE ST
Provider Business Mailing Address City Name:
CROOKSTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56716-0603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-281-3940
Provider Business Mailing Address Fax Number:
218-281-6261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
603 BRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROOKSTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-281-3940
Provider Business Practice Location Address Fax Number:
218-281-6261
Provider Enumeration Date:
03/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  09419 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1031784 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6252818 . This is a "UBH MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 116598 . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP28519 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 17964 . This is a "BCBS OF ND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 9H592AN . This is a "BCBS BHSI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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