Provider Demographics
NPI:1366401481
Name:ANDERSON, BRENDA MELISSIA (LICSW)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:MELISSIA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:MELISSIA
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 603
Mailing Address - Street 2:603 BRUCE ST
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-0603
Mailing Address - Country:US
Mailing Address - Phone:218-281-3940
Mailing Address - Fax:218-281-6261
Practice Address - Street 1:603 BRUCE ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716
Practice Address - Country:US
Practice Address - Phone:218-281-3940
Practice Address - Fax:218-281-6261
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN094191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1031784OtherPREFERRED ONE
6252818OtherUBH MEDICA
MN116598OtherUCARE MINNESOTA
HP28519OtherHEALTH PARTNERS
ND17964OtherBCBS OF ND
MN9H592ANOtherBCBS BHSI