1114129947 NPI number — DR. KIM MARIE ANDERSON PHD LCSW SW002258

Table of content: DR. KIM MARIE ANDERSON PHD LCSW SW002258 (NPI 1114129947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114129947 NPI number — DR. KIM MARIE ANDERSON PHD LCSW SW002258

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
KIM
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD LCSW SW002258
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114129947
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 BUSINESS LOOP 70 W
Provider Second Line Business Mailing Address:
SUITE 153B
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-499-4572
Provider Business Mailing Address Fax Number:
573-256-1183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 BUSINESS LOOP 70 W
Provider Second Line Business Practice Location Address:
SUITE 153B
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-499-4572
Provider Business Practice Location Address Fax Number:
573-256-1183
Provider Enumeration Date:
06/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW002258LCSW , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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