Provider Demographics
NPI:1356632921
Name:ANDERSON, KATHLEEN ANNE (LMHC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ANNE
Other - Last Name:KOUIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:6221 LAKE LUGANO DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8438
Mailing Address - Country:US
Mailing Address - Phone:904-327-7192
Mailing Address - Fax:
Practice Address - Street 1:9140 GOLFSIDE DR
Practice Address - Street 2:12N
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1881
Practice Address - Country:US
Practice Address - Phone:904-327-7192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4062101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional