Basic Information
| Provider Information | |||||||||
| NPI: | 1659608792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW-CC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 ATLANTIC PL | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078427701 | ||||||||
| FaxNumber: | 2078427773 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 SPRINGBROOK DR | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040059443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072821500 | ||||||||
| FaxNumber: | 2072822581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2009 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MC12040 | ME | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | MC12040 | ME | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 434971299 | 05 | ME | MEDICAID |