Healthcare Provider Details

I. General information

NPI: 1417597329
Provider Name (Legal Business Name): KIMBERLY WYBORNEY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CROSBY RD STE 1
DOVER NH
03820-4370
US

IV. Provider business mailing address

113 CROSBY RD STE 1
DOVER NH
03820-4370
US

V. Phone/Fax

Practice location:
  • Phone: 603-516-9300
  • Fax:
Mailing address:
  • Phone: 603-516-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1853
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: