Healthcare Provider Details

I. General information

NPI: 1255439535
Provider Name (Legal Business Name): DANIEL J KIMBALL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 JEFFERSON ST STE 410
LAFAYETTE LA
70501-7900
US

IV. Provider business mailing address

905 JEFFERSON ST STE 410
LAFAYETTE LA
70501-7900
US

V. Phone/Fax

Practice location:
  • Phone: 337-234-4912
  • Fax: 337-234-6064
Mailing address:
  • Phone: 337-234-4912
  • Fax: 337-234-6064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3916
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: