Provider Demographics
NPI:1578550968
Name:ANDERSON, KIMBERLY LEE (MSW, LCSW, ATR)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSW, LCSW, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 OAKLAND AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1870
Mailing Address - Country:US
Mailing Address - Phone:314-805-9421
Mailing Address - Fax:314-298-9983
Practice Address - Street 1:7110 OAKLAND AVE STE 104
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1870
Practice Address - Country:US
Practice Address - Phone:314-805-9421
Practice Address - Fax:314-644-7144
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW0023241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495868614Medicaid
MO000082290Medicare ID - Type Unspecified