Provider Demographics
NPI:1962462879
Name:ANDERSON, KIMBERLY RESNICK (LISW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RESNICK
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N MAIN ST
Mailing Address - Street 2:SUITE 408
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44310-3110
Mailing Address - Country:US
Mailing Address - Phone:330-379-5005
Mailing Address - Fax:330-379-5562
Practice Address - Street 1:444 N MAIN ST
Practice Address - Street 2:SUITE 408
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44310-3110
Practice Address - Country:US
Practice Address - Phone:330-379-5005
Practice Address - Fax:330-379-5562
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00077781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHANSW24451Medicare ID - Type Unspecified
P50326Medicare UPIN