Provider Demographics
NPI:1932153053
Name:ANDERSON KHAN, KIMBERLY J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:J
Last Name:ANDERSON KHAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:J
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC PAIN MANAGEMENT
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-6969
Mailing Address - Fax:414-266-1761
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC PAIN MANAGEMENT
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-6969
Practice Address - Fax:414-266-1761
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2412103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39138900Medicaid
009000261HOtherHUMANA
WI1932153053Medicaid
009000261HOtherHUMANA
P76456Medicare UPIN