Provider Demographics
NPI:1730442294
Name:KIMYATTA ANDERSON
Entity type:Organization
Organization Name:KIMYATTA ANDERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMYATTA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW,LCAS
Authorized Official - Phone:252-753-5100
Mailing Address - Street 1:PO BOX 4204
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27836-2204
Mailing Address - Country:US
Mailing Address - Phone:252-753-5100
Mailing Address - Fax:252-753-5121
Practice Address - Street 1:3707 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828-1486
Practice Address - Country:US
Practice Address - Phone:252-753-5100
Practice Address - Fax:252-753-5121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0056121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106660Medicaid