Healthcare Provider Details

I. General information

NPI: 1558344523
Provider Name (Legal Business Name): KENDALL F BACON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 SOUTH ST
FITCHBURG MA
01420
US

IV. Provider business mailing address

855 MOUNTAIN RD
JAFFREY NH
03452
US

V. Phone/Fax

Practice location:
  • Phone: 978-345-4147
  • Fax: 978-345-1616
Mailing address:
  • Phone: 603-532-8615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number105716
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number105716
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105716
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: