Provider Demographics
NPI:1366249559
Name:ANDERSON, KENNETH DOW (CAC, CADC, RSS)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DOW
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CAC, CADC, RSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PALMER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1139
Mailing Address - Country:US
Mailing Address - Phone:860-214-5857
Mailing Address - Fax:
Practice Address - Street 1:330 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3652
Practice Address - Country:US
Practice Address - Phone:860-214-5857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000803101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)