Provider Demographics
NPI:1386841633
Name:ANDERSON, KIMBERLY CARSON (SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CARSON
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 480462
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5320
Mailing Address - Country:US
Mailing Address - Phone:704-258-1724
Mailing Address - Fax:704-598-3024
Practice Address - Street 1:1805 MOUNT ISLE HARBOR DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28214-5405
Practice Address - Country:US
Practice Address - Phone:704-258-1724
Practice Address - Fax:704-598-3024
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4039235Z00000X
NC8790235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC20-3092660OtherTAX ID