Healthcare Provider Details

I. General information

NPI: 1790065571
Provider Name (Legal Business Name): KIMBERLY SCANNELL LICSW, MLADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 PALOMINO LN STE 101
BEDFORD NH
03110-6447
US

IV. Provider business mailing address

80 PALOMINO LN STE 101
BEDFORD NH
03110-6447
US

V. Phone/Fax

Practice location:
  • Phone: 603-324-8181
  • Fax: 734-396-1041
Mailing address:
  • Phone: 603-324-8181
  • Fax: 734-396-1041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1545
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0597
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: