Healthcare Provider Details

I. General information

NPI: 1134219678
Provider Name (Legal Business Name): JOAN KUNDIN DOUBLEDAY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W PARK ST
LEBANON NH
03766-1378
US

IV. Provider business mailing address

20 W PARK ST
LEBANON NH
03766-1378
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-9925
  • Fax: 802-295-2441
Mailing address:
  • Phone: 603-448-9925
  • Fax: 802-295-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number239
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number181
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: