Provider Demographics
NPI:1609279926
Name:ANDERSON, KIMBERLY (MA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 E VIA PLAZA NUEVA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-8491
Mailing Address - Country:US
Mailing Address - Phone:505-231-6078
Mailing Address - Fax:
Practice Address - Street 1:42 E VIA PLAZA NUEVA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-8491
Practice Address - Country:US
Practice Address - Phone:505-231-6078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM303701103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool