MEDICARE: KIM GWYNN ANDERSON

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	106S00000X	Behavior Technician		NC

General Provider Information

NPI Number	:	1528925187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM GWYNN ANDERSON

Provider Business Mailing Address
First Line	:	1950 MALLARD LAKES DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-8615
Country	:	US
Telephone Number	:	336-930-4863
Fax Number	:

Provider Business Practice Location Address
First Line	:	1950 MALLARD LAKES DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-8615
Country	:	US
Telephone Number	:	336-930-4863
Fax Number	:

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

Provider Enumeration Date	:	01/06/2026
Last Update Date	:	01/06/2026

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