Healthcare Provider Details

I. General information

NPI: 1275768244
Provider Name (Legal Business Name): EDWARD JOSEPH KIMMEL JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 EVERSMAN DRIVE
JASPER IN
47547-0769
US

IV. Provider business mailing address

PO BOX 769 480 EVERSMAN DRIVE
JASPER IN
47547-0769
US

V. Phone/Fax

Practice location:
  • Phone: 812-482-3020
  • Fax: 812-482-6409
Mailing address:
  • Phone: 812-482-3020
  • Fax: 812-482-6409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34001093A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: