Basic Information
| Provider Information | |||||||||
| NPI: | 1487697009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOUSE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUNT | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 99 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044570099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077946700 | ||||||||
| FaxNumber: | 2077946777 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 WEST BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044570000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077946700 | ||||||||
| FaxNumber: | 2077946777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 12/04/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LC9962 | ME | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 161040200 | 05 | ME | MEDICAID | 161040206 | 05 | ME | MEDICAID | 098304 | 01 | ME | ANTHEM LEGACY NUMBER | OTHER | 205890199 | 05 | ME | MEDICAID | 161040203 | 05 | ME | MEDICAID | 161040205 | 05 | ME | MEDICAID | 161040204 | 05 | ME | MEDICAID |