Healthcare Provider Details

I. General information

NPI: 1295766186
Provider Name (Legal Business Name): AMY B ANDERSON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 67TH ST
KENOSHA WI
53142-3836
US

IV. Provider business mailing address

4109 67TH ST
KENOSHA WI
53142-3836
US

V. Phone/Fax

Practice location:
  • Phone: 262-652-9830
  • Fax: 262-652-2931
Mailing address:
  • Phone: 262-652-9830
  • Fax: 262-652-2931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2045
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number969-123
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-005163
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: