Provider Demographics
NPI:1699125500
Name:ANDERSON, NANCY JO (MA, LMFT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:JO
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 WILLOW ST
Mailing Address - Street 2:STE # 400
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2269
Mailing Address - Country:US
Mailing Address - Phone:763-544-0306
Mailing Address - Fax:
Practice Address - Street 1:1409 WILLOW ST
Practice Address - Street 2:STE # 400
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2269
Practice Address - Country:US
Practice Address - Phone:763-544-0306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLMFT 234106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist