Provider Demographics
NPI:1356828578
Name:FANTINI, KIMBERLY C (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:C
Last Name:FANTINI
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 1:49 STONY BROOK RD
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-1903
Mailing Address - Country:US
Mailing Address - Phone:978-697-1808
Mailing Address - Fax:
Practice Address - Street 1:49 STONY BROOK RD
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-1903
Practice Address - Country:US
Practice Address - Phone:978-697-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0001213511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical