Healthcare Provider Details

I. General information

NPI: 1285830364
Provider Name (Legal Business Name): KATHLEEN SUSAN ANDERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 NORTH ROAD LEXINGTON CENTER FOR RECOVERY MMTP
POUGHKEEPSIE NY
12601
US

IV. Provider business mailing address

43 ROLLING RIDGE ROAD
HYDE PARK NY
12538
US

V. Phone/Fax

Practice location:
  • Phone: 845-486-2850
  • Fax: 845-486-2770
Mailing address:
  • Phone: 845-849-3542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number3666721
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: