Provider Demographics
NPI:1457674475
Name:ANDERSON, KIMBERLY R
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
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 1030
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-1030
Mailing Address - Country:US
Mailing Address - Phone:580-298-2830
Mailing Address - Fax:
Practice Address - Street 1:2816 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4250
Practice Address - Country:US
Practice Address - Phone:580-326-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation