Provider Demographics
NPI:1144939489
Name:ANDERSON, KEVIN RYAN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:RYAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 GILLHAM RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:785-643-0704
Mailing Address - Fax:
Practice Address - Street 1:2401 GILLHAM RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-4619
Practice Address - Country:US
Practice Address - Phone:785-643-0704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04147101YP2500X
MO2025020602101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional