Provider Demographics
NPI:1326297763
Name:CAMPBELL, KIMBERLY ANNE (MSW, LICSW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:LABERGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:10 TSIENNETO RD
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038
Mailing Address - Country:US
Mailing Address - Phone:603-434-1577
Mailing Address - Fax:603-226-7508
Practice Address - Street 1:10 TSIENNETO RD
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038
Practice Address - Country:US
Practice Address - Phone:603-434-1577
Practice Address - Fax:603-226-7508
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC111171041C0700X
15631041C0700X
1041C0700X
NHMC111171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432604999Medicaid