Provider Demographics
NPI:1831562305
Name:OTTERNESS, ANDREA (LADC)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:
Last Name:OTTERNESS
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 WEST BROADWAY AVE SUITE 2
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025
Mailing Address - Country:US
Mailing Address - Phone:651-777-5222
Mailing Address - Fax:651-251-5279
Practice Address - Street 1:555 W BROADWAY AVE STE 1AND2
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1175
Practice Address - Country:US
Practice Address - Phone:651-777-5222
Practice Address - Fax:651-251-5279
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302520101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)