Provider Demographics
NPI:1134556624
Name:ANDERSON, KEVIN JOSEPH
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 DUDLEY ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2769
Mailing Address - Country:US
Mailing Address - Phone:617-445-6655
Mailing Address - Fax:
Practice Address - Street 1:520 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2769
Practice Address - Country:US
Practice Address - Phone:508-208-4656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS40107772101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0000023532OtherBMC
MA042611055OtherTAX ID
MA1303287Medicaid
MA99618201OtherNETWORTH HEALTH
MAM18633OtherBCBS
MA1004745OtherNHP
MA1303287OtherMBHP
MA1303287Medicaid