Provider Demographics
NPI:1174178743
Name:KIMBALL, MELISSA ANN (CRSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:KIMBALL
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 1:60 ROGERS ST UNIT 204
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5070
Mailing Address - Country:US
Mailing Address - Phone:603-724-4859
Mailing Address - Fax:
Practice Address - Street 1:60 ROGERS ST UNIT 204
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-5070
Practice Address - Country:US
Practice Address - Phone:603-724-4859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0211101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0211Medicaid