Provider Demographics
NPI:1962747006
Name:ANDERSEN, KRISTY LEE
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:LEE
Last Name:ANDERSEN
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 1:3515 N BRONCO ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4807
Mailing Address - Country:US
Mailing Address - Phone:702-339-3489
Mailing Address - Fax:
Practice Address - Street 1:5130 S PECOS RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1248
Practice Address - Country:US
Practice Address - Phone:888-753-3302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health