Healthcare Provider Details

I. General information

NPI: 1922081793
Provider Name (Legal Business Name): KRISTIN KIMMELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N WALNUT ST SUITE 800
BLOOMINGTON IN
47404-3982
US

IV. Provider business mailing address

205 N WALNUT ST SUITE 800
BLOOMINGTON IN
47404-3982
US

V. Phone/Fax

Practice location:
  • Phone: 812-332-6992
  • Fax:
Mailing address:
  • Phone: 812-332-6992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34000505A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: