Provider Demographics
NPI:1326871690
Name:FORTIN, KIMBERLY ANN (CRSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:FORTIN
Suffix:
Gender:F
Credentials:CRSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ELLIOT WAY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-3599
Mailing Address - Country:US
Mailing Address - Phone:603-663-4430
Mailing Address - Fax:
Practice Address - Street 1:1 ELLIOT WAY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-3599
Practice Address - Country:US
Practice Address - Phone:603-663-4430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0327101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)