Provider Demographics
NPI:1619080132
Name:BERNARD, KINDRA THRELKELD (LCPC)
Entity Type:Individual
Prefix:
First Name:KINDRA
Middle Name:THRELKELD
Last Name:BERNARD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HIGH ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2831
Mailing Address - Country:US
Mailing Address - Phone:207-251-5359
Mailing Address - Fax:
Practice Address - Street 1:200 HIGH ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2831
Practice Address - Country:US
Practice Address - Phone:207-251-5359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3547101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432160299Medicaid