MEDICARE: KENYA DIVANA ANDERSON LCSW-A

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	1041C0700X	Clinical Social Worker	P014855	NC

General Provider Information

NPI Number	:	1679175640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYA DIVANA ANDERSON LCSW-A

Provider Business Mailing Address
First Line	:	210 OAKTON GLEN CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1756
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 OAKTON GLEN CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1756
Country	:	US
Telephone Number	:	210-883-5231
Fax Number	:

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

Provider Enumeration Date	:	11/13/2020
Last Update Date	:	12/02/2020

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