Provider Demographics
NPI:1063591840
Name:ANDERSEN, AMY SUE (MPT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SUE
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7645 BEHM LN
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-2902
Mailing Address - Country:US
Mailing Address - Phone:651-784-7389
Mailing Address - Fax:
Practice Address - Street 1:1970 OAKCREST AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2624
Practice Address - Country:US
Practice Address - Phone:651-636-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist