=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649724824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BARRIE DAIGNEAULT LICSW LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2016
-----------------------------------------------------
Last Update Date | 08/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53 MAMMOTH RD
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03109-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-867-2974
-----------------------------------------------------
Fax | 603-666-7177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 MAMMOTH RD
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03109-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-867-2974
-----------------------------------------------------
Fax | 603-666-7177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICIAN
-----------------------------------------------------
Name | BARRIE DAIGNEAULT
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 603-867-2974
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 848
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------