Basic Information
| Provider Information | |||||||||
| NPI: | 1760527956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | BRANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRANN | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9 BODWELL ST | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040112801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077295861 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25 WESTMINSTER ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042403531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077820079 | ||||||||
| FaxNumber: | 2077822636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | LC6837 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.