Healthcare Provider Details

I. General information

NPI: 1205310638
Provider Name (Legal Business Name): AUTUMN ROSE KENDAL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 STILLWATER AVE
OLD TOWN ME
04468-1665
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-404-8000
  • Fax:
Mailing address:
  • Phone: 207-404-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC20123
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: