Healthcare Provider Details

I. General information

NPI: 1245569250
Provider Name (Legal Business Name): KIMBERLY M POLAND LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY M. CORNWALL LCPC

II. Dates (important events)

Enumeration Date: 12/22/2009
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 LANCASTER ST
PORTLAND ME
04101-2406
US

IV. Provider business mailing address

78 ATLANTIC PL
SOUTH PORTLAND ME
04106-2316
US

V. Phone/Fax

Practice location:
  • Phone: 207-956-3258
  • Fax: 207-874-1044
Mailing address:
  • Phone: 207-661-6654
  • Fax: 207-842-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC3538
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: