Provider Demographics
NPI:1578604997
Name:STRUCK, KIMBERLY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:STRUCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:SCHOOLING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14 WYONEGONIC RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009-4652
Mailing Address - Country:US
Mailing Address - Phone:207-647-9021
Mailing Address - Fax:207-647-5932
Practice Address - Street 1:14 WYONEGONIC RD
Practice Address - Street 2:
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-4652
Practice Address - Country:US
Practice Address - Phone:207-647-9021
Practice Address - Fax:207-647-5932
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC82141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical