Basic Information
Provider Information
NPI: 1003012253
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MILLS
FirstName: KIMBERLY
MiddleName: ANN
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 78 ATLANTIC PL
Address2:  
City: SOUTH PORTLAND
State: ME
PostalCode: 041062316
CountryCode: US
TelephoneNumber: 2078427708
FaxNumber: 2078427773
Practice Location
Address1: 12 UNION ST
Address2:  
City: ROCKLAND
State: ME
PostalCode: 048412739
CountryCode: US
TelephoneNumber: 2078427708
FaxNumber: 2078427773
Other Information
ProviderEnumerationDate: 06/25/2007
LastUpdateDate: 07/08/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700XLC12830MEY Behavioral Health & Social Service ProvidersSocial WorkerClinical
1041C0700X11114MEN Behavioral Health & Social Service ProvidersSocial WorkerClinical

ID Information
IDTypeStateIssuerDescription
100301225305ME MEDICAID


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