Provider Demographics
NPI:1801361548
Name:ANTONELL, KIM RYNEARSON (LICSW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:RYNEARSON
Last Name:ANTONELL
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 1:1 WILDFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-2332
Mailing Address - Country:US
Mailing Address - Phone:508-561-9002
Mailing Address - Fax:508-358-4773
Practice Address - Street 1:1 WILDFLOWER LN
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-2332
Practice Address - Country:US
Practice Address - Phone:508-561-9002
Practice Address - Fax:508-358-4773
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1053501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA105350OtherMASS LICENSE