Healthcare Provider Details

I. General information

NPI: 1205987930
Provider Name (Legal Business Name): KATHLEEN A ANDERSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 BEDFORD ST
WHITMAN MA
02382-1820
US

IV. Provider business mailing address

53 CUSTER ST
ROCKLAND MA
02370-1926
US

V. Phone/Fax

Practice location:
  • Phone: 781-447-6425
  • Fax: 781-447-1786
Mailing address:
  • Phone: 781-878-2317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114334
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1012537
Identifier TypeMEDICAID
Identifier StateVT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: