Healthcare Provider Details

I. General information

NPI: 1073598629
Provider Name (Legal Business Name): KIMBLE L RICHARDSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7165 CLEARVISTA WAY
INDIANAPOLIS IN
46256-4621
US

IV. Provider business mailing address

6626 E 75TH STREET STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-5756
  • Fax:
Mailing address:
  • Phone: 317-621-7561
  • Fax: 317-355-6096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000004A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34002814A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35000369A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: