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General NPI Number Information
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NPI Number | 1730442294
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Entity Type | Organization
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Legal Business Name | KIMYATTA ANDERSON
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Dates
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Enumeration Date | 06/20/2012
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Last Update Date | 06/21/2012
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Provider Practice Location Address
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Address Line | 3707 N MAIN ST
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City | FARMVILLE
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State | NC
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Zip | 27828-1486
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Country | US
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Telephone | 252-753-5100
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Fax | 252-753-5121
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Provider Business Mailing Address
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Address Line | PO BOX 4204
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City | GREENVILLE
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State | NC
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Zip | 27836-2204
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Country | US
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Telephone | 252-753-5100
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Fax | 252-753-5121
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MRS. KIMYATTA ANDERSON
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Credential | LCSW,LCAS
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Telephone | 252-753-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C005612
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License Number State | NC
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