Provider Demographics
NPI:1275347858
Name:ANDERSON, KRISTIN NICOLE (LMSW)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:NICOLE
Other - Last Name:BROMLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2518 TOLANI TRL
Mailing Address - Street 2:C/O KRISTIN ANDERSON
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86005-3797
Mailing Address - Country:US
Mailing Address - Phone:435-669-8386
Mailing Address - Fax:
Practice Address - Street 1:201 E BIRCH AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-5215
Practice Address - Country:US
Practice Address - Phone:435-669-8386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-208851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1285347518Medicaid