Provider Demographics
NPI:1013135946
Name:ANDERSON, KAY KELLY (MED)
Entity Type:Individual
Prefix:MRS
First Name:KAY
Middle Name:KELLY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MED
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 89
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:ID
Mailing Address - Zip Code:83555-0089
Mailing Address - Country:US
Mailing Address - Phone:208-791-8544
Mailing Address - Fax:208-743-5358
Practice Address - Street 1:1995 WINCHESTER ROAD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:ID
Practice Address - Zip Code:83555
Practice Address - Country:US
Practice Address - Phone:208-791-8544
Practice Address - Fax:208-743-5358
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC2976101YM0800X
IDLMFT2977106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807346100Medicaid
ID806910400Medicaid
ID806984800Medicaid
ID807384700Medicaid
ID806983200Medicaid