Provider Demographics
NPI:1447602743
Name:ANDERSON, KIMBERLY KAY (LISW)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:KAY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 CAMP CARDINAL BLVD
Mailing Address - Street 2:BOX 2271
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241
Mailing Address - Country:US
Mailing Address - Phone:319-594-8010
Mailing Address - Fax:319-356-2587
Practice Address - Street 1:2421 CORAL COURT
Practice Address - Street 2:SUITE #129
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241
Practice Address - Country:US
Practice Address - Phone:319-322-8887
Practice Address - Fax:319-356-2587
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA05940104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0409321Medicaid