Healthcare Provider Details

I. General information

NPI: 1265256754
Provider Name (Legal Business Name): KATIE KIMBALL LCPC-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MIDDLE ST
PORTLAND ME
04101-4869
US

IV. Provider business mailing address

258 US ROUTE 1
SCARBOROUGH ME
04074-8904
US

V. Phone/Fax

Practice location:
  • Phone: 207-553-3378
  • Fax:
Mailing address:
  • Phone: 207-553-3378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberXL6935
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberXL6935
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: