Provider Demographics
NPI:1134367154
Name:ANDERSEN, KIRSTEN ANNE
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:ANNE
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2432 GRAND CONCOURSE RM 201
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5211
Mailing Address - Country:US
Mailing Address - Phone:718-817-7098
Mailing Address - Fax:718-562-9426
Practice Address - Street 1:2432 GRAND CONCOURSE RM 201
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5211
Practice Address - Country:US
Practice Address - Phone:718-817-7098
Practice Address - Fax:718-562-9426
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11715-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical