Healthcare Provider Details

I. General information

NPI: 1851454383
Provider Name (Legal Business Name): KIMBRAY NICHOLE MCNEAL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 11/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BODIN CIRCLE
TRAVIS AFB CA
94535-2941
US

IV. Provider business mailing address

385 SNOW EGRET DR
VACAVILLE CA
95687-7749
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5174
  • Fax:
Mailing address:
  • Phone: 757-291-7445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0903001464
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8445
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: