Provider Demographics
NPI:1780233536
Name:ANDERSON, KALEY RAE
Entity type:Individual
Prefix:
First Name:KALEY
Middle Name:RAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56048-9796
Mailing Address - Country:US
Mailing Address - Phone:507-995-8636
Mailing Address - Fax:
Practice Address - Street 1:1891 STATION PKWY NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3341
Practice Address - Country:US
Practice Address - Phone:763-755-4275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
MN528302235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst