Provider Demographics
NPI:1316303928
Name:ANDERSON, TIMOTHY JAMES (MSLMFT)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MSLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7251 EXCELSIOR RD
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8477
Mailing Address - Country:US
Mailing Address - Phone:218-454-0878
Mailing Address - Fax:218-454-0879
Practice Address - Street 1:7251 EXCELSIOR RD
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425
Practice Address - Country:US
Practice Address - Phone:218-232-6067
Practice Address - Fax:218-454-0879
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2900106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNL642115036912OtherDRIVERS LICENSE NUMBER
MN2900OtherMINNESOTA STATE LMFT NUMBER