Provider Demographics
NPI:1063614568
Name:ANDERSON, DALE ROBERT (MS CPRP)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:ROBERT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MS CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2390
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-2390
Mailing Address - Country:US
Mailing Address - Phone:320-650-1544
Mailing Address - Fax:320-650-1528
Practice Address - Street 1:157 ROOSEVELT RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-5478
Practice Address - Country:US
Practice Address - Phone:320-240-3324
Practice Address - Fax:320-240-3339
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1692772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry