Provider Demographics
NPI:1740452416
Name:LIGHTBEAR, KIMBERLY DENA (MA LADC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DENA
Last Name:LIGHTBEAR
Suffix:
Gender:F
Credentials:MA LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819
Mailing Address - Country:US
Mailing Address - Phone:802-748-8842
Mailing Address - Fax:802-748-9014
Practice Address - Street 1:108 CHERRY STREET
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:802-748-8842
Practice Address - Fax:802-748-9014
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000418101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)