Provider Demographics
NPI:1386382588
Name:DERESSA, ANOGSA
Entity type:Individual
Prefix:
First Name:ANOGSA
Middle Name:
Last Name:DERESSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W FRANKLIN AVE APT 123
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2312
Mailing Address - Country:US
Mailing Address - Phone:763-923-1247
Mailing Address - Fax:
Practice Address - Street 1:315 W FRANKLIN AVE APT 123
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2312
Practice Address - Country:US
Practice Address - Phone:763-923-1247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health