Healthcare Provider Details

I. General information

NPI: 1538637228
Provider Name (Legal Business Name): BRENDA FORTIER-DUBE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MOUNT EUSTIS RD
LITTLETON NH
03561-3712
US

IV. Provider business mailing address

218 BICKFORD HILL RD
FRANCONIA NH
03580-4800
US

V. Phone/Fax

Practice location:
  • Phone: 603-444-2464
  • Fax:
Mailing address:
  • Phone: 603-823-9019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2052
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: