Provider Demographics
NPI:1205987930
Name:ANDERSON, KATHLEEN A (LICSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 CUSTER ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:MA
Mailing Address - Zip Code:02370-1926
Mailing Address - Country:US
Mailing Address - Phone:781-878-2317
Mailing Address - Fax:
Practice Address - Street 1:288 BEDFORD ST
Practice Address - Street 2:
Practice Address - City:WHITMAN
Practice Address - State:MA
Practice Address - Zip Code:02382-1820
Practice Address - Country:US
Practice Address - Phone:781-447-6425
Practice Address - Fax:781-447-1786
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1143341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012537Medicaid