Provider Demographics
NPI:1902088099
Name:ANDERSON, DELAINE BETH (MED LAC)
Entity type:Individual
Prefix:MS
First Name:DELAINE
Middle Name:BETH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MED LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CENTRAL AVE S
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-3325
Mailing Address - Country:US
Mailing Address - Phone:701-845-2498
Mailing Address - Fax:701-845-9984
Practice Address - Street 1:202 CENTRAL AVE S
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-3325
Practice Address - Country:US
Practice Address - Phone:701-845-2498
Practice Address - Fax:701-845-9984
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1163101YA0400X
ND1423101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)