Healthcare Provider Details

I. General information

NPI: 1356433734
Provider Name (Legal Business Name): RONALD LEE KIMBALL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 BURKET CT
SILVER SPRING MD
20910-1355
US

IV. Provider business mailing address

4 BURKET CT
SILVER SPRING MD
20910-1355
US

V. Phone/Fax

Practice location:
  • Phone: 202-452-6257
  • Fax: 301-608-2624
Mailing address:
  • Phone: 202-452-6257
  • Fax: 301-608-2624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY886
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY886
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY886
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPSY886
License Number StateDC
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number00775
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: