Provider Demographics
NPI:1396310108
Name:ANDERSON, KIMBERLY A
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
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 1:617 E 97TH ST APT 306
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4380
Mailing Address - Country:US
Mailing Address - Phone:323-715-6678
Mailing Address - Fax:
Practice Address - Street 1:30 E 23RD ST FL 7
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4440
Practice Address - Country:US
Practice Address - Phone:646-493-9464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health