MEDICARE: KIMBERLY CARSON ANDERSON SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	4039	SC
2	235Z00000X	Speech-Language Pathologist	8790	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20-3092660	OTHER	NC	TAX ID

General Provider Information

NPI Number	:	1386841633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY CARSON ANDERSON SLP

Provider Business Mailing Address
First Line	:	PO BOX 480462
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-5320
Country	:	US
Telephone Number	:	704-258-1724
Fax Number	:	704-598-3024

Provider Business Practice Location Address
First Line	:	1805 MOUNT ISLE HARBOR DRIVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214-5405
Country	:	US
Telephone Number	:	704-258-1724
Fax Number	:	704-598-3024

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2007
Last Update Date	:	06/13/2013

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Directions to “ KIMBERLY CARSON ANDERSON SLP” Practice Location

Language	Start Address	Practice Location

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