Provider Demographics
NPI:1295843712
Name:ANDERSON, KIM B (PT)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:B
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:868 TARA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611
Mailing Address - Country:US
Mailing Address - Phone:337-885-6536
Mailing Address - Fax:
Practice Address - Street 1:1717 E PRIEN LAKE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-0400
Practice Address - Country:US
Practice Address - Phone:337-478-5880
Practice Address - Fax:337-478-5879
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05283208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C591Medicare ID - Type Unspecified