Provider Demographics
NPI:1124072996
Name:WOOD BACON, KATHLEEN M (LICSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:WOOD BACON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 CHESTNUT ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-3012
Mailing Address - Country:US
Mailing Address - Phone:603-836-5003
Mailing Address - Fax:
Practice Address - Street 1:183 ROCKINGHAM ROAD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:NH
Practice Address - Zip Code:03087
Practice Address - Country:US
Practice Address - Phone:603-434-9937
Practice Address - Fax:603-434-0427
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHLICSW1238104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
RE8182Medicare ID - Type Unspecified