=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083677975
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIM KNOWLES PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 PLEASANT HILL RD STE 204
-----------------------------------------------------
City | SCARBOROUGH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04074-9688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-799-6166
-----------------------------------------------------
Fax | 207-885-1062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2121
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04116-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-767-1260
-----------------------------------------------------
Fax | 207-767-1261
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS977
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------