Healthcare Provider Details

I. General information

NPI: 1861762908
Provider Name (Legal Business Name): KIMBERLY PLOETTNER LMHC, LCDCS, LCDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N MAIN ST
PROVIDENCE RI
02904-5762
US

IV. Provider business mailing address

40 LISA LN
HOPE VALLEY RI
02832-1241
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC00859
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP00509
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: