Provider Demographics
NPI:1356744908
Name:WALLANT, KIM (LCPC, RPT, ATR)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:WALLANT
Suffix:
Gender:F
Credentials:LCPC, RPT, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 WOODMANS MILL RD
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04941-4637
Mailing Address - Country:US
Mailing Address - Phone:561-351-4256
Mailing Address - Fax:
Practice Address - Street 1:865 WOODMANS MILL RD
Practice Address - Street 2:
Practice Address - City:MONTVILLE
Practice Address - State:ME
Practice Address - Zip Code:04941-4637
Practice Address - Country:US
Practice Address - Phone:561-351-4256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC6610101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional