Provider Demographics
NPI:1578751020
Name:ANDERSON, KEVIN D (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 N MULFORD RD
Mailing Address - Street 2:CONDO #1
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5190
Mailing Address - Country:US
Mailing Address - Phone:815-395-1141
Mailing Address - Fax:815-395-1117
Practice Address - Street 1:461 N MULFORD RD
Practice Address - Street 2:CONDO #1
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5190
Practice Address - Country:US
Practice Address - Phone:815-395-1141
Practice Address - Fax:815-395-1117
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK06813Medicare UPIN