Provider Demographics
NPI:1790904779
Name:NICHOLAS ANDERSON, KRISTINA (LSW, MASTERS STUDENT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:
Last Name:NICHOLAS ANDERSON
Suffix:
Gender:F
Credentials:LSW, MASTERS STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5624 N GOVERNMENT WAY
Mailing Address - Street 2:SUITE 7B
Mailing Address - City:DALTON GARDENS
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7350
Mailing Address - Country:US
Mailing Address - Phone:208-762-9890
Mailing Address - Fax:208-762-9892
Practice Address - Street 1:5624 N GOVERNMENT WAY
Practice Address - Street 2:SUITE 7B
Practice Address - City:DALTON GARDENS
Practice Address - State:ID
Practice Address - Zip Code:83815-7350
Practice Address - Country:US
Practice Address - Phone:208-762-9890
Practice Address - Fax:208-762-9892
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-2298104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLSW-2298OtherBUR OCCUP LICEN - LSW