Provider Demographics
NPI:1669867511
Name:ANDERSON, KEVIN SCOTT (EDS, LP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:SCOTT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:EDS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 12TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-4009
Mailing Address - Country:US
Mailing Address - Phone:507-440-0134
Mailing Address - Fax:
Practice Address - Street 1:111 N MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-3474
Practice Address - Country:US
Practice Address - Phone:507-440-0134
Practice Address - Fax:855-748-3132
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3823103TC0700X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN38734400Medicaid
MN38734400Medicaid