Provider Demographics
NPI:1982863312
Name:ANDERSON, KEITH A (MSW)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46527-0809
Mailing Address - Country:US
Mailing Address - Phone:574-283-1234
Mailing Address - Fax:574-537-2652
Practice Address - Street 1:403 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2322
Practice Address - Country:US
Practice Address - Phone:574-283-1234
Practice Address - Fax:574-537-2652
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IN34006132A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health