Basic Information
| Provider Information | |||||||||
| NPI: | 1639840663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSEN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | SUDCC III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1646 S COURT ST | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932774962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597364840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1646 S COURT ST | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932774962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596258890 | ||||||||
| FaxNumber: | 5597335053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2021 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 10218 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.