Provider Demographics
NPI:1114129947
Name:ANDERSON, KIM MARIE (PHD LCSW SW002258)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD LCSW SW002258
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 BUSINESS LOOP 70 W
Mailing Address - Street 2:SUITE 153B
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203
Mailing Address - Country:US
Mailing Address - Phone:573-499-4572
Mailing Address - Fax:573-256-1183
Practice Address - Street 1:601 BUSINESS LOOP 70 W
Practice Address - Street 2:SUITE 153B
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203
Practice Address - Country:US
Practice Address - Phone:573-499-4572
Practice Address - Fax:573-256-1183
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW002258LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical