Provider Demographics
NPI:1558344523
Name:BACON, KENDALL F (MSW)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:F
Last Name:BACON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:JAFFREY
Mailing Address - State:NH
Mailing Address - Zip Code:03452
Mailing Address - Country:US
Mailing Address - Phone:603-532-8615
Mailing Address - Fax:
Practice Address - Street 1:915 SOUTH ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420
Practice Address - Country:US
Practice Address - Phone:978-345-4147
Practice Address - Fax:978-345-1616
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105716101YM0800X, 104100000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
127184OtherTRICARE
MAP07079OtherBCBS
P20100Medicare ID - Type Unspecified