Provider Demographics
NPI:1215238431
Name:BURGESS, KIMBERLY ANN (LSW-C, BHP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LSW-C, BHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1373
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1373
Mailing Address - Country:US
Mailing Address - Phone:207-667-3239
Mailing Address - Fax:207-667-0171
Practice Address - Street 1:23 CARRIAGE WAY
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605
Practice Address - Country:US
Practice Address - Phone:207-667-3239
Practice Address - Fax:207-667-0171
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX12393104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker