Healthcare Provider Details

I. General information

NPI: 1952521924
Provider Name (Legal Business Name): KIMYATTA SHEVONE ANDERSON LCSW, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 N MAIN ST
FARMVILLE NC
27828-1486
US

IV. Provider business mailing address

PO BOX 4204
GREENVILLE NC
27836-2204
US

V. Phone/Fax

Practice location:
  • Phone: 252-753-5100
  • Fax: 252-753-5121
Mailing address:
  • Phone: 252-753-5100
  • Fax: 252-753-5121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005612
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: