Provider Demographics
NPI:1285741819
Name:ANDERSON, GREGORY T (LP)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:T
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 EAST FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:214 W SUPERIOR ST
Practice Address - Street 2:SKYWALK LEVEL
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1904
Practice Address - Country:US
Practice Address - Phone:218-722-2273
Practice Address - Fax:218-726-1183
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1457103TC1900X
MN73411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1016110OtherPREFERRED ONE BHP
MN46092OtherOPTUM
MN024 R1LAOtherBLUE CROSS/BLUE SHIELD
MN943752500Medicaid
MN106621OtherU CARE
MN62-21313OtherMEDICA / UBH