Provider Demographics
NPI:1194976407
Name:ANDERSON, MARIE LYNN (PSYD, LP, LMFT)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PSYD, LP, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12760 ABERDEEN ST NE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5845
Mailing Address - Country:US
Mailing Address - Phone:651-600-2727
Mailing Address - Fax:612-656-3031
Practice Address - Street 1:12760 ABERDEEN ST NE
Practice Address - Street 2:SUITE 212
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5845
Practice Address - Country:US
Practice Address - Phone:651-600-2727
Practice Address - Fax:612-656-3031
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1701106H00000X
MN5635103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist