=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548944176
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY DONALDSON ANDERSON MA - ED, IECE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2023
-----------------------------------------------------
Last Update Date | 06/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 532 MERRYWOOD DR
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42025-7642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-556-9561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 532 MERRYWOOD DR
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42025-7642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-556-9561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 19901475
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------